Leydig Cell Tumor of the Testis. New Cases and Review of the Current Literature

Leydig cell tumors are the most frequent non-germ cell tumors of the testis, accounting for 1-3% of all testicular tumors. They present most commonly as a testicular mass or with endocrine symptoms. We report three new cases of Leydig cell tumori that presented in different forms. The relevant literature is reviewed and the management of these tumors is discussed.

[Malignant Leydig Cell Tumor of the Testis : A Case Report]

A 69-year-old Japanese man was referred to our hospital for a left inguinal testicular tumor and paraaortic lymph node swelling and pleural dissemination. A left orchiectomy was performed in October 2013. Histologically, this testicular tumor was a malignant Leydig cell tumor. The antineoplastic agent mitotan was administered after the orchiectomy. Two months later, although his plasma level of testosterone had de-escalated, the para-aortic lymph node did not decrease in size. A retroperitoneal lymph node dissection was performed in January 2014. Unfortunately, three days after the surgery, the patient died due to disseminated intravascular coagulation and gastrointestinal hemorrhage of unknown cause.

Metastasized Leydig cell tumor in a dog

We present the clinical findings, diagnosis and treatment of an 11-year old intact male Fox Terrier with a malignant Leydig cell tumor of the right testicle, which metastasized to the skeletal musculature of the left hind limb. The primary tumor and the metastasis were resected with narrow margins. The dog was treated with metronomic chemotherapy using thalidomid and dyclophosphamide. Local recurrence at the site of the metastasis and a pulmonary metastasis were present 30 months after surgery. The dog was euthanized.

An in-depth look at Leydig cell tumor of the testis

Leydig cell tumor (LCT) is a rare tumor of the male testicular interstitium. This article provides an overview of the major pathologic manifestations of LCT of the testis; patient characteristics; clinical, radiologic, and laboratory features; prognosis; and management. LCTs of the testis are frequently hormonally active, leading to either feminizing or virilizing syndromes. The tumor is usually benign, but malignant variants can occur. The pathologic diagnosis of LCT is usually made based on morphologic characteristics of the tumor cells. The significance of Reinke crystals in the diagnosis of LCT both cytologically and histologically is underscored. Pathologists have to be familiar with the diagnostic histopathologic features, immunohistochemical panel of this tumor, and its principal differential diagnoses to prevent tumor misdiagnosis.

[Leydig cell tumor. Case report and review of the literature]

OBJECTIVE

To report a new case of the rare Leydig cell tumor, and to perform bibliographic review.

METHODS

We report the case of a 38-year-old male with the clinical and ultrasound diagnosis of testicular tumor, and normal hormonal and extension studies. He underwent inguinal radical orchyectomy and the pathology report of the specimen showed a Leydig cell tumor. It was staged as T1N0M0, not receiving any further treatment with chemotherapy or radiotherapy. Five years after surgery there is no evidence of disease on follow-up.

RESULTS

The patient does not show evidence of recurrence after chest x-rays, abdominal-pelvic CT scan, ultrasound of the contralateral testis, and tumor markers.

CONCLUSIONS

We recommend a long-term follow-up with contralateral testicle ultrasound, CT scan, chest x-ray, and tumor markers.

A novel targeted therapy of Leydig and granulosa cell tumors through the luteinizing hormone receptor using a hecate-chorionic gonadotropin beta conjugate in transgenic mice

We investigated the antitumoral efficacy, endocrine consequences, and molecular mechanisms underlying cell death induced by the Hecate-chorionic gonadotropin (CG)beta conjugate, a fusion protein of a 23-amino acid lytic peptide Hecate with a 15-amino acid (81-95) fragment of the human CGbeta chain. Transgenic (TG) mice expressing the inhibin alpha-subunit promoter (inhalpha)/Simian Virus 40 T-antigen (Tag) transgene, developing luteinizing hormone (LH) receptor (R) expressing Leydig and granulosa cell tumors, and wild-type control littermates were treated either with vehicle, Hecate, or Hecate-CGbeta conjugate for 3 weeks. Hecate-CGbeta conjugate treatment reduced the testicular and ovarian tumor burden (P < .05), whereas a concomitant increase (testis; P < .05) or no change (ovary) in tumor volumes occured with Hectate treatment. A drop in serum progesterone, produced by the tumors, and an increase in LH levels occured in Hecate-CGbeta treated mice, in comparison with vehicle and Hecate groups, providing further support for the positive treatment response. Hecate-CGbeta conjugate induced a rapid and cell-specific membrane permeabilization of LHR-expressing cells in vitro, suggesting a necrotic mode of cell death without activation of apoptosis. These results prove the principle that the Hecate-CGbeta conjugate provides a novel specific lead into gonadal somatic cell cancer therapy by targeted destruction of LHR-expressing tumor cells.

[Testicular tumors--a current review]

Only 1% of all male tumors are testicular origin, but it is the most frequent neoplasia in younger men. Risk factors include cryptorchism and a positive personal history of testicular cancer. Testicular cancer is divided in germ cell cancer and non germ cell cancer, the latter accounting for about 5%. Germ cell cancer is classified in seminoma and nonseminoma. Usually the first clinical presentation is painless swelling. Afterwards ultrasonography is indicated and tumor markers should be analysed. The first therapeutic step is always a radical inguinal orchiectomy. The following treatment depends on the staging: wait and see, radiotherapy or chemotherapy. Testicular cancer is characterised by a good cure rate (98-100% early stages) or recurrence free survival (80-90% late stages).

The influence of photodynamic reaction on R2C cells

Photodynamic therapy (PDT) represents a therapeutic approach in which photosensitised neoplastic cells undergo destruction under effect of light. In this study we have attempted to define effects of photochemotherapy on R2C cells, sensitised with protoporphyrin IX (PpIX) and to find out whether inhibition of gene expression by cycloheximide affects development of lesions in the cells. The photosensitised cells were exposed to visible light and development of apoptotic and necrotic lesions was followed in the cells, using the fluorescent staining with propidium iodide and Hoechst 33342. The experiments demonstrated that PpIX and light, acting in parallel, induce development of apoptotic and necrotic lesions in R2C cells. Intensity of the lesions correlated with concentration of the applied photosensitiser and with duration of light exposure. Using cycloheximide, we also inhibited protein expression in cells photosensitised with protoporphyrin before they were exposed to light. In the latter case, development of apoptosis was clearly intensified which might be explained by inhibition of anti-apoptotic protein synthesis in the cells.

[Ovarian Leydig cell tumor]

INTRODUCTION

Leydig cell tumors are sex cord-stromal tumors with sexual steroid production (predominantly testosterone). They account for less than 0.6% of ovarian neoplasms and mostly appear at the age of 28.

HISTOPATHOLOGY

It is a solid yellowish nodular tumor, less than 5 cm in diameter. It consists of polygonal Leydig cells, eosinophillic cytoplasm with lipid vacuole and lipochrome pigments. Nuclei are oval, pleomorphic with rare nucleoli. Hyperthecosis is around the tumor.

CASE DESCRIPTION

Signs and symptoms depend on age of women and testosterone levels. Women complain about hirsutism, hoarseness, muscular hypertrophy, increased libido, clitoromegaly, temporal hair loss and menstrual disturbances.

DIAGNOSIS

Basal hormone analysis reveals extremely high testosterone levels, mildly high androstenedione and 17 OH progesterone, and suppressed follicle stimulating hormone and luteinizing hormone. Estradiol, dehydroepiandrosterone sulfate and other hormones are normal. Dexamethasone screening test decreases dehydroepioandrosterone sulfate and androstenedion, whereas testosterone levels are only partly suppressed. Human choriogonadotropin test is clearly stimulatory for testosterone. Suppressed gonadotropin levels do not respond to luteinizing hormone releasing hormone stimulation. Ultrasonography, nuclear magnetic imaging, Doppler sonography, ovarian vein catheterization can be used for visualization. The removal of tumor is followed by normalization of testosterone levels, increase of gonadotropins and gradual disappearance of all symptoms and signs.

THERAPY

The only effective therapy is operative.

Leydig cell tumors and tumors associated with congenital adrenal hyperplasia

Testicular cancers occur at a rate of 2 cases per 100,000 males. Gonadal stromal tumors, including Leydig cell tumors and tumors of the adrenogenital syndrome, account for 1% to 3% of these neoplasms. Despite their rarity, these hormone-producing tumors are particularly interesting because of their potential for causing endocrinologic manifestations in prepubertal and adult males. They are also clinically significant, and early identification is critical to avoid profound and often irreversible developmental changes in affected children. An accurate diagnosis is important to differentiate tumors that will respond to medical management from tumors that require definitive surgical therapy.

[Leydig-cell tumors of the testis]

The authors review case histories of 23 patients with leydigomas selected from records on 134 patients with nongerminogenic testicular tumors. Malignancy occurred in 6 cases. Two cases with uni- and bilateral testicular involvement are reported. The course of leydigoma in children is described.

Metachronous germ cell and Leydig cell tumors of the testis. Do testicular germ cell tumors and Leydig cell tumors share common etiologic factors?

BACKGROUND

Testicular germ cell neoplasms occur bilaterally in approximately 2-5% of patients. Bilateral testicular tumors of different histogenesis are extremely rare, and the study of such cases may offer clues to the pathogenesis of both tumor entities.

METHODS

A report of a case and review of the literature are presented.

RESULTS

A 33-year-old man had a right-sided testicular neoplasm consisting of teratoma, embryonal carcinoma, and yolk sac tumor. Retroperitoneal lymph node metastases were excised, and, subsequently, adjuvant abdominal radiation therapy was administered. The patient later received six cycles of cisplatin-based chemotherapy for pulmonary relapse. When he was 40 years of age, a contralateral Leydig cell tumor (LCT) was treated by testis-sparing excision. This is the first observation of testicular germ cell tumor (GCT) and contralateral LCT. Three cases of germ cell neoplasm and concurrent ipsilateral LCT have been reported previously.

CONCLUSIONS

The association of GCT and LCT in one patient is quite unusual because both entities are rare. Sharing of common etiologic factors by both entities is a possible explanation.

Treatment of malignant Leydig cell tumor

Malignant Leydig cell tumors (LCT) are rare. Only 32 cases of malignant LCT (as evidenced by metastatic spread) were reported. Generally metastatic spread occurs within 2 years of the primary LCT, and the patient dies within 2 years of the discovery of metastatic disease. The tumor is highly resistant to both radiation and chemotherapy. It also has a great propensity for recurring after surgical resection. A case is reported of a patient whose metastatic disease occurred 8 years after his primary LCT had been resected. He was treated with doxorubicin and mitotane without response. The clinical features of this case are highlighted, and a review of the literature describing treatment of this rare disease is presented.

Long-term follow-up of children with testicular tumours: surgical issues

Testicular tumours are rare in childhood. The clinical, pathological and follow-up details of 48 children are presented. The combined approach of surgery, chemotherapy and radiotherapy is confirmed as being extremely effective. Transcrotal orchiectomy is not an appropriate surgical procedure. Testicular biopsy is detrimental to prognosis.

Malignant Leydig cell tumour of the testis: a case report and review of the literature

A rare case of malignant Leydig cell tumour of the testis is presented. There was no standard therapy regimen. Leydig cell carcinoma is relatively refractory to radiotherapy and chemotherapy. So a retroperitoneal node dissection should be performed before or after chemotherapy for staging and also for therapeutic reasons.

[Leydig cell tumor of the testis. Therapeutic and anatomopathologic clinical study of 2 new cases]

Tumors of the testis comprise 1% of male neoplasms. Interstitial cell tumors that originate in Leydig's cells account for 1 to 3% of these testicular tumors. A prognosis is difficult to make since these rare neoplasms manifest clinically in variable forms and it is extremely difficult to distinguish the benign from the malignant. Two new cases of this rare tumor type seen at the Department of Urology of the University Hospital of Florence are reported. The literature is reviewed, highlighting the clinical aspects, particularly the symptomatic, histopathologic, and the differential diagnostic features of the less and highly malignant forms. Furthermore, a protocol for selecting the therapeutic modality for this rare neoplasm is described.

Ovarian Sertoli-Leydig cell tumour with raised serum alpha fetoprotein. A case report

A case of ovarian Sertoli-Leydig cell tumour with a raised serum alpha fetoprotein is reported. The patient first presented at the age of 27 years with a history of 6 years' amenorrhoea followed by 3 months irregular vaginal bleeding. A ovarian tumour was found and excised and shown microscopically to be a spindle cell malignant tumour. The patient was treated with chemotherapy and had a complete response. Thirty months after first presentation there was a recurrence in the pelvis which microscopically showed the typical features of a Sertoli-Leydig cell tumour. Six months later a second recurrence had the microscopic appearance of a lipid cell tumour. A raised serum alpha fetoprotein was found at the time of the second recurrence and immunohistochemistry showed this protein in the Leydig and luteinized cells of the recurrent tumours but not in the spindle cells of the original ovarian neoplasm.

Gonadal stromal tumors: a report of the Prepubertal Testicular Tumor Registry

A total of 15 gonadal stromal tumors in prepubertal boys has been reported to the Prepubertal Testicular Tumor Registry of the Section on Urology of the American Academy of Pediatrics. Leydig cell tumors invariably are benign and patients usually present with precocious puberty when they are 5 to 9 years old. Other gonadal stromal tumors either present in infancy as a scrotal mass and exhibit a benign behavior or occur later in childhood and may be malignant.

Ovarian Sertoli-Leydig cell tumors. A clinicopathological analysis of 207 cases

The clinical and pathological features of 207 ovarian Sertoli-Leydig cell tumors from our consultation and hospital files were reviewed. The patients ranged in age from 2 to 75 (average 25) years. Seventy-five percent of them were 30 years of age or younger and less than 10% were over 50 years of age. One-third of the patients presented because of unequivocal evidence of androgen excess, and an additional 10% had a history suggesting androgen excess; most of the remaining patients complained of abdominal swelling or pain. At operation, 97.5% of the tumors were Stage I, 1.5% were Stage II, and 1% were Stage III. Both ovaries were involved in 1.5% of the cases. The tumors ranged from microscopic to 51 cm in diameter (average 13.5 cm); 15% of them were ruptured. Thirty-eight percent of the tumors were solid, 58% were solid and cystic, and 4% were cystic. The solid tissue was typically lobulated and yellow. On microscopic examination, 11% of the tumors were well differentiated, 54% were of intermediate differentiation, 13% were poorly differentiated, and 22% contained heterologous elements according to the criteria of the World Health Organization; a prominent retiform pattern was present in 15% of them. Follow-up was obtained for 164 patients. The tumor was clinically malignant in 18% of them. The prognosis correlated most meaningfully with the stage and degree of differentiation of the tumor. The high-stage tumors were all clinically malignant. All the well-differentiated tumors were benign, but 11% of those of intermediate differentiation, 59% of the poorly differentiated tumors, and 19% of those with heterologous elements were malignant. In a few cases radiation therapy, chemotherapy, or a combination of the two, in addition to surgical excision, was of benefit in the management of the malignant tumors.

Sertoli-Leydig tumors of the ovary. A clinicopathologic study of 64 intermediate and poorly differentiated neoplasms

The clinical and pathologic features of 64 Sertoli-Leydig tumors of the ovary with intermediate and poor differentiation were studied. The neoplasms occurred mainly in young women. Fifty-four percent of the patients presented with clinical evidence of a hormonally active tumor, and 38% were virilized. The remaining 46% had nonspecific symptoms. Sixty-two patients had tumors confined to one ovary at operation (Stage Ia), while only two patients presented with pelvic metastases (Stage III). The prognosis was generally favorable; the 5- and 10-year actuarial survival rates were 92%. Unilateral salpingo-oophorectomy was effective treatment for Stage Ia Sertoli-Leydig tumors in young women. Microscopically, 44 of the neoplasms were of intermediate differentiation and 20 were poorly differentiated. Heterologous elements (mucinous epithelium, striated muscle, cartilage) were present in 16 neoplasms. The pathologic features that correspond with development of metastases were poor differentiation, the presence of heterologous mesenchymal elements, frequent mitotic figures in stromal cells, and rupture of the neoplasm.

Ovarian Sertoli-Leydig cell tumors with heterologous elements. I. Gastrointestinal epithelium and carcinoid: a clinicopathologic analysis of thirty-six cases

Thirty-six ovarian Sertoli-Leydig cell tumors containing heterologous elements in the form of gastrointestinal-type epithelium are described. Eight of the cases contained microscopic foci of insular carcinoid; in two of these cases of foci of goblet cell carcinoid were also present. The patients' ages ranged from 4-67 years (average, 23 years). The presenting manifestations were androgenic changes (18 cases), abdominal swelling (15 cases), acute abdominal symptoms (one case), menstrual irregularities (one case), and postmenopausal bleeding (two cases). All of the tumors were unilateral. The surface of the tumor was intact in 32 cases, ruptured in three, and adherent to the diaphragm in one. The tumors usually had both cystic and solid components and averaged 15.0 cm in diameter; mucinous fluid was noted on gross examination in 12 cases. On microscopic examination, the gastrointestinal epithelium contained mucinous cells, columnar cells and argentaffin cells; rarely Paneth cells were seen. It was cytologically benign in 29 cases, of borderline malignancy in five and malignant in two. Follow-up information, available for 31 patients, revealed that 29 were alive without evidence of disease from 1-17 years (average, six years) postoperatively. One patient, who had a poorly differentiated tumor, died of recurrent disease six years after the initial operation.

Ovarian Sertoli-Leydig cell tumors with heterologous elements. II. Cartilage and skeletal muscle: a clinicopathologic analysis of twelve cases

Twelve ovarian Sertoli-Leydig cell tumors that contained heterologous elements in the form of skeletal muscle (nine cases), cartilage (seven cases) and neuroblastoma (one case) in either the primary of recurrent specimens are reported. Four of the primary tumors also contained foci of gastrointestinal type epithelium with argentaffin cells identifiable in two of them. The age of the patients ranged from 11-48 years (average, 24 years). Ten patients presented with an abdominal mass, one with abdominal pain and one with acute abdominal symptoms. Five of the patients, two of whom were virilized and one of whom was hirsute, had evidence establishing or suggesting androgen overproduction. All the tumors were unilateral. Four had ruptured preoperatively and two ruptured during the operation. The tumors averaged 18.5 cm in greatest diameter and had extensive areas of hemorrhage and necrosis in half the cases. On microscopic examination the Sertoli-Leydig cell component was poorly differentiated in 11 cases and of intermediate differentiation in one case. In two cases the primary tumor was a poorly differentiated Sertoli-Leydig cell tumor and heterologous elements were identified only in a recurrent mass. Follow-up of ten patients revealed that eight of them had died of tumor from five months to seven years postoperatively.

Malignant interstitial cell carcinoma of the testis: report of two cases with steroid synthetic profiles, response to therapy, and review of the literature

Two cases of malignant interstitial cell carcinoma of the testis are reported. The first patient had no evidence of a virilizing syndrome. Basal plasma testosterone (T) was decreased, whereas plasma luteinizing hormone, estrone (E1), and androstenedione were elevated. These findings were diagnostic of a defect in T secretion as a result of a partial 17-hydroxysteroid dehydrogenase deficiency as seen in male pseudohermaphroditism. In the second patient, showing gynecomastia and atrophic testis, endocrine studies revealed high plasma T and estradiol (E2); all measured delta 4 and delta 5 precursors of T were elevated resembling the pattern seen in virilizing adrenal carcinomas. Both patients were treated with radiotherapy without demonstrable effect. Chemotherapy--consisting of a combination of cis-platinum, vinblastine, and bleomycin; then cyclophosphamide, doxorubicin, and vincristine; and finally o,p'-DDD--was unsuccessful in reducing tumor bulk. Since malignant Leydig cell carcinomas are rare, this paper reviews the literature and makes recommendations concerning treatment.

[Malignant interstitial cell tumor of testis with a marker enzyme (author's transl)]

Metastatic interstitial cell tumor of the testis is one of the rarest human neoplasms. This is the nineteenth case to be reported. While most of these tumors are combined with hormonal dysfunction, the present tumor, apart from its uncommon hormonal profile, is remarkable because of its capacity of producing and secreting a marker enzyme, alkaline phosphatase. No response was seen after cytostatic therapy with new antineoplastic agents, such as a combination of adriamycin and cis-diamminedichloride-platinum (II), and ifosfamide. Considering the lack of radiosensitivity, surgery is the primary modality of treatment.

Interstitial cell tumor of testis: a delicate problem

Interstitial cell tumor of the testis is a rare tumor in humans. There have been 39 cases reported in children and 13 malignant tumors in adults. Two cases of interstitial cell tumor in childhood, 5 benign types in adults, and 2 malignant tumors are presented herein. In regard to the therapeutic consequences, a plea is made to define the malignant potential of the tumor on histologic criteria alone.

Leydig cell tumor of testis

In adult patients with Leydig cell tumor of the testis, endocrinologic signs occur in 30 per cent of the cases and often precede the onset of a palpable testicular mass. Gynecomastia is the most common endocrinologic manifestation and probably is due to increased estrogen secretion by the Leydig cells. In the patient with adrenogenital syndrome and testicular enlargement it is difficult to distinguish Leydig cell tumor from adrenal rest hypertrophy. Four patients with Leydig cell tumor and endocrinologic manifestations are discussed; three are adults who presented with gynecomastia and the fourth is a patient with congenital adrenogenital syndrome. In the adult patient inguinal orchiectomy is the treatment of choice, while in the patient with adrenogenital syndrome initial management by high-dose steroid suppression should be attempted prior to testicular exploration.

The management of testicular tumors in children

Of 43 testicular tumors in children seen at the Children's Hospital Medical Center and Sidney Farber Cancer Institute 33 were malignant. These tumors occurred primarily in young children. Any solid scrotal mass in an infant must be considered malignant until proved otherwise. Primary emphasis is placed on the 20 cases of embryonal cell carcinoma. Of 9 patients who underwent only orchiectomy 5 have died, whereas all 11 patients who received combination therapy have survived. We recommend radical inguinal orchiectomy, extended unilateral retroperitoneal lymphadenectomy and adjuvant chemotherapy in repeated courses for 2 years. Radiotherapy is withheld if the lymphadenectomy is negative.

Testicular tumors in infants and children

Forty three children with testicular tumors have been presented. Eighty per cent of these tumors were malignant, and 60 per cent occurred in children less than two and one half years of age. Twenty of the 24 malignant germinal tumors were embryonal cell carcinomas. The mean age of the patients at presentation of these tumors was 18 months. Nine patients underwent orchiectomy alone, and five of these have died. Eleven received combined therapy, and all have survived. We currently recommend radical orchiectomy and extended unilateral retroperitoneal lymphadenectomy. If examination of the nodes reveals evidence of metastases, a bilateral dissection is done. Radiotherapy is given only in the presence of nodal metastases. Adjuvant chemotherapy with vincristine, actinomycin D, and Cytoxan is given for two years to all patients with malginant nonseminomatous germ cell tumors or sarcomas.