Gynecomastia disclosing diagnosis of Leydig cell tumour in a man with thalassemia, secondary hypogonadism and testis microlithiasis

Aim of this paper is to report about a 35-year old man suffering from beta-Thalassemia major and longstanding untreated hypogonadotropic hypogonadism, who was referred because of a recent onset and painful bilateral gynecomastia, with no palpable testicular masses. Due to the finding of a solid mass at left testis ultrasonography, monolateral testicular exeresis was performed and histology revealed a Leydig Cell Tumour and testicular microlithiasis. Post-surgical restoration of testosterone/estradiol ratio under testosterone therapy was followed by a very rapid reduction of gynecomastia. Our report confirms the usefulness of scrotal ultrasonography for finding an occult testicular tumour in a patient with painful and recent onset bilateral gynecomastia and underlines: a) the important role of testosterone/estradiol ratio in the pathophysiology of gynecomastia; b) the questionable significance of testicular microlithiasis as marker of testis tumours; c) the possible association between beta-Thalassemia and tumoral pathologies.

Efficacy of selective venous catheterization in localizing a small androgen-producing tumor in ovary

BACKGROUND

Androgen-producing tumors, originating mostly in the ovary or adrenal gland, induce hirsutism. It sometimes is difficult to localize the tumor precisely even with modern imaging technology. We used selective venous catheterization and hormonal sampling (SVCHS) to localize an androgen-producing ovarian tumor.

CASE REPORT

A 37-year-old woman (gravida 0, para 0) presented with secondary amenorrhea, infertility, and virilization, including hirsutism and progressive balding. Laboratory examination revealed severe hyperandrogenism, with a total testosterone (T) concentration of 13.1 ng/ml and a free T concentration of 28.1 pg/ml. Dehydroepiandrosterone sulfate and androstendione were within normal ranges. Work-up included an abdominal and pelvic ultrasound scan, CT, MRI, and norcholesterol scintigraphy without discovery of the source of the hyperandrogenism. Persistently high plasma T concentrations prompted SVCHS. Eleven blood samples were collected from both the adrenal and the ovarian veins bilaterally. The total T concentration was significantly higher in blood from the right ovarian vein (878 ng/ml). A laparoscopic right oophorectomy was performed. The pathologic diagnosis was a Leydig cell tumor. A rapid decrease in free and total T followed tumor removal, and she became pregnant by in vitro fertilization.

CONCLUSIONS

SVCHS is highly effective in confirming the presence of a small androgen-producing ovarian tumor.

Leydig cell tumor after treatment for Ewing's sarcoma

Leydig cell tumors account for 3% of testicular tumors and have never been reported after treatment for Ewing's sarcoma. We report the unusual occurrence of a patient who developed a Leydig cell tumor of the testis 18 years after successful treatment for Ewing's sarcoma. Additional monitoring for second malignancies may become appropriate as long-term survival continues to improve for patients with Ewing's sarcoma.

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.

Conservative Surgical Therapy for Leydig Cell Tumor

PURPOSE

We performed a long-term evaluation of conservative surgical treatment of benign Leydig cell tumor.

MATERIALS AND METHODS

A multicenter retrospective clinical study was performed at 6 European centers. Case files of all patients diagnosed with Leydig cell tumor and treated with conservative surgery were examined. Patients underwent physical examination, hormone and tumor marker assays, scrotal and abdominal ultrasound, chest x-ray, and an endocrinological examination.

RESULTS

From 1987 to 2006, 22 patients with Leydig cell tumor underwent conservative surgery. Mean patient age was 35 years (range 5 to 61). Mean followup was 47 months (range 1 to 230). No local recurrence or metastasis was observed. Patients presented with a palpable testicular nodule (3 patients, 13.7%) or a nodule diagnosed by ultrasound (15 patients, 68.2%), gynecomastia (2 patients, 9.1%), precocious pseudopuberty (1 patient, 4.5%) or scrotal pain (1 patient, 4.5%). Three patients were monorchid after contralateral orchiectomy for inguinal hernia repair (1 patient, 28 years before surgery) and nonseminomatous germ cell tumor (2 patients, 1 month and 6 years before surgery). Diagnosis after frozen section examination was Leydig cell tumor in 20 of 22 cases (91.0%). Mean histological size of the nodule was 1.11 cm (range 0.5 to 2.5). Preoperative FSH and LH levels were high in 4 patients. Tumor markers were normal before and after surgery. Followup was conducted for all patients every 3 to 6 months with physical examination, tumor markers, scrotal and abdominal ultrasound, chest x-ray. Six patients (27.3%) underwent abdominal computerized tomography.

CONCLUSIONS

When diagnosed early Leydig cell tumors present a favorable followup. In select cases with motivated patients, conservative surgery proved to be a feasible and safe choice.

Long-term followup after elective testis sparing surgery for Leydig cell tumors: a single center experience

PURPOSE

Although most Leydig cell tumors are benign, radical orchiectomy is currently considered the standard therapy. We retrospectively analyzed the long-term followup of a series of patients with Leydig cell tumors electively treated with testis sparing surgery.

MATERIALS AND METHODS

Between November 1990 and December 2005, 17 consecutive patients with Leydig cell tumors underwent testis sparing surgery on an elective basis. Preoperative evaluation included physical examination, serum markers for germ cell tumors, scrotal ultrasound, abdominal computerized tomography, chest x-ray and hormonal profile if clinically required. Testis sparing surgery was performed via an inguinal approach with spermatic cord clamping. Frozen section examination was performed in all cases, revealing Leydig cell tumors. Followup consisted of physical examination, scrotal ultrasound, abdominal computerized tomography and chest x-ray every 6 months for the first 2 years, then annually. Tumor recurrence and survival were evaluated.

RESULTS

Mean patient age was 41.6 years (range 28 to 55). Medical referral was prompted by symptoms/signs such as infertility, gynecomastia or self-palpation of scrotal mass in 11 patients (64.7%), while in the remaining 6 (35.3%) the lesions were incidentally diagnosed. Hormonal profile was performed in 9 patients, showing abnormalities in all. Mean tumor diameter was 13.4 mm (range 5 to 31). Definitive pathological examination confirmed benign Leydig cell tumor in all cases. After a mean followup of 91 months (range 12 to 192), neither local recurrence nor distant metastases have been detected and all patients are alive without evidence of disease.

CONCLUSIONS

In patients with Leydig cell tumors testis sparing surgery with frozen section examination provides an excellent long-term oncological outcome.

[MRI for the diagnosis of Leydig cell testicular tumors]

OBJECTIVE

To determine the diagnostic usefulness of MRI in the diagnosis of Leydig cell testicular tumor.

METHODS/RESULTS

Male patient consulting for infertility. Testicular ultrasound and MRI were performed. Testicular MRI showed a hypointense lesion in T2 powered sequences with intense, homogeneous enhance after contrast administration.

CONCLUSIONS

MRI is considered an excellent diagnostic test for the management of patients with testicular diseases of difficult diagnosis on ultrasound, contributing to define the lesion, a Leydig cell testicular tumor in this case.

Androgenproduzierender Leydig-Zell-Tumor des Ovars als Ursache von Hirsutismus bei einer postmenopausalen Frau

BACKGROUND

Hirsutism or virilization in postmenopausal women may be due to increased testosterone levels caused by an androgen-secreting tumor. The preoperative localization of small ovarian or adrenal androgen-secreting tumors is difficult.

CASE REPORT

A 61-year-old, postmenopausal woman presented with progressive hirsutism and deepening of voice over the last 9 years. Serum testosterone was very high (almost 30 nmol/l). Computed tomographic (CT) scans of the adrenals and ultrasonography of the pelvis were negative. Selective catheterization and [(18)F]FDG-PET/CT investigation raised the suspicion of an androgen-secreting tumor of the right ovary. Oophorectomy was performed, and a Leydig cell tumor of the right ovary was confirmed on histological examination.

CONCLUSION

Selective catheterization and [(18)F]FDG-PET investigation may aid the detection of androgen-secreting tumors.

Bilateral Leydig cell tumour of the ovary: a rare cause of virilization in postmenopausal patient

BACKGROUND

Leydig cell tumours of the ovary are very rare benign neoplasms, frequently associated with symptoms of virilisation, in postmenopausal patients. Only four cases of bilateral Leydig tumours have been reported in the literature.

CASE REPORT

We report an additional case of bilateral presentation. A 77-year-old postmenopausal patient was referred from the Endocrinology Service due to a biochemical diagnosis of hyperandrogenism during hospital admission with unbalanced diabetes mellitus. The patient had suffered from alopecia and hirsutism for many years. Biological data confirmed an increment of androgen production. Ultrasonography showed a well-defined hyperechoic lesion of 12 mm in the right ovary. A CT scan demonstrated adrenal glands and ovaries without tumour. Bilateral adnexectomy by laparoscopy was carried out.

RESULT

The pathological finding was a bilateral Leydig cell tumour, measuring 15 mm in the right ovary and 3 mm in the left ovary. Following treatment the patient experienced regression of the hirsutism and the plasma testosterone dropped to a normal level.

CONCLUSION

In spite of its low incidence, it is a possibility that must be considered in all postmenopausal women with hyperandrogenism, and bilateral adnexectomy by laparoscopy is recommended as a diagnostic test and definitive treatment.

Long-Term Followup and Clinical Characteristics of Testicular Leydig Cell Tumor: Experience With 24 Cases

PURPOSE

The natural history of Leydig cell testicular tumors is not well known, and differentiation between malignant and benign forms is not easy. We performed a retrospective multicenter evaluation of clinical and histological characteristics as well as followup of Leydig cell tumors.

MATERIALS AND METHODS

From 1990 to August 2004 surgery was performed on 24 Leydig cell tumors. Before surgery all patients underwent clinical examination, tumor markers (alpha-fetoprotein, beta-human chorionic gonadotropin, lactate dehydrogenase), scrotal ultrasound and chest x-ray. Surgery was performed under ultrasound or palpation guidance via inguinotomy with clamping of the spermatic cord. Lesions less than 3 cm in diameter were resected and sent for frozen section examination. Histological criteria were considered. Abdominal computerized tomography or ultrasound and chest x-ray were performed postoperatively every 3 months for the first 2 years and every 6 months thereafter.

RESULTS

Patient age range was 22 to 61 years (mean 37.75). In 7 patients (29.2%) the lesion was palpable and incidental diagnosis was made in 10 patients (41.7%). In the other patients diagnosis was made by ultrasound performed for testicular pain (4 patients, 16.6%) or the appearance of gynecomastia (3 patients, 12.5%). Frozen section examination was done in 20 of 24 patients (83%). In 17 of 20 patients (85%) Leydig cell tumor was diagnosed on frozen section examination. All patients underwent radical orchiectomy. All definitive diagnoses interpreted the neoplasia as benign. Average followup was 117 months (range 11 to 241). There was no disease recurrence or progression and all patients are currently disease-free.

CONCLUSIONS

In our case study all Leydig cell tumors were interpreted as benign and long-term followup was negative.

[Gynaecomastia and male infertility as symptoms of a nonpalpable Leydig cell tumour]

A 35-year-old man and his partner were referred for intracytoplasmic sperm injection treatment (ICSI) because of secondary infertility due to severe oligoasthenoteratospermia. Three years earlier he had presented elsewhere with left unilateral gynaecomastia. A hypertrophic mammary gland had been excised one year later. Histopathological investigation showed benign hypertrophy. One year later he developed gynaecomastia on the other side. Physical examination and incomplete hormonal screening showed no abnormalities. The couple were referred to our tertiary clinic for ICSI treatment. The patient still had unilateral gynaecomastia. Hormonal screening showed not only severe oligoasthenoteratospermia, but also an elevated serum oestrogen level. Scrotal ultrasound revealed a 17 mm mass in his right testicle. Subsequently unilateral orchidectomy was performed. Histology showed a benign Leydig cell tumour for which no further therapy was required. Four months after surgery the gynaecomastia diminished, oestrogen levels became normal and improvement in semen parameters followed. Patients with severe male infertility or gynaecomastia are at a higher risk of developing a testicular neoplasm. Besides history taking, physical examination of breasts and testicles, hormonal screening and scrotal sonography should be performed as some testicular neoplasms are not apparent on palpation.

[Leydig cell tumor: our experience. Bibliographic review]

OBJECTIVES

To report the case-series of Leydig cell tumors diagnosed at our center, and to perform a bibliographic review on the topic.

METHODS

Retrospective review of the clinical records of all patients with the diagnosis of Leydig cell tumor in our center over the last 12 years. We evaluated the clinical, diagnostic and therapeutic features, as well as outcomes.

RESULTS

Four patients were diagnosed and treated in our department over this period. Mean patient age of the time of diagnosis was 51 years. Each of our cases have a different presentation. The two patients who underwent sperm analysis had azoospermia. None of the cases showed anomalous hormonal studies. Seventy-five percent of the cases showed ultrasound signs compatible with testicular neoplasia. In all of them surgical treatment was undertaken (inguinal orchyectomy); one of the patients underwent chemotherapy due to metastasis, having a good response. Mean follow-up is 76 months.

CONCLUSIONS

It is a rare testicular tumor. Inguinal orchyectomy is the treatment of choice. Its good outcome is remarkable.

A malignant Leydig cell tumor of the testis

A 40-year-old man was referred to our hospital with gynecomastia and painless swelling of the right scrotum. Ultrasonography revealed a 15 x 10 mm mass with low echogenicity of the right testis. We performed right high orchiectomy. Histologically, Reinke's crystals and capsular invasion by tumor cells were found. Final diagnosis, the tumor was a malignant Leydig cell tumor of the testis.

[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.

[Follow-up in a boy with Leydig cell tumor after selective surgery]

A 8(6/12) year-old-boy presented with precocious puberty and a slightly enlarged left testis. After a detailed examination a Leydig cell tumour was diagnosed. Surgical exploration revealed an encapsulated tumour, 2.7 cm in length, which was selectively removed without orchidectomy. Within one year the clinical signs of pubertal precocity disappeared, the bone age did not further advance and height velocity declined from 8.2 cm / year (+3.9 SDS) to 4.1 cm/year (-1.0 SDS). Physiologically, he entered puberty at the chronological age of twelve years, presenting at that age, in comparison to his peer group, a slightly decreased pubertal growth spurt. However, bearing in mind that being precocious in puberty he started in fact his pubertal growth spurt at a far earlier age, therefore, this acceleration of height before operation has to be added to the centimetres gained during pubertal development thereafter resuiting consequently in an absolute normal pubertal growth spurt. This underlines the fact that the individual growth spurt and, therefore, the total amount of centimetres gained is very much robust. Ten years later, the patient ended up well within his familial target height and remained free of disease. We report on a long-term follow-up of a prepubertal boy after testis-sparing surgery for Leydig-cell-tumour.

[An uncommon cause of gynecomastia: testicular Leydig cell tumor. Hormonal profile before and after orchiectomy]

Leydig cell tumors (LTC) are uncommon neoplasms arising from gonadal stroma that account for 1-3% of all testicular tumors. We report a case of LCT in a 36 years old man who had been suffering from painful bilateral gynecomastia for one year. Endocrine function tests showed decreased gonadotropin concentrations, and reduction of testosterone/estradiol ratio. Ultrasonography revealed a 10-12 mm hypoechoic area in the right testis, not evident on physical examination. Right orchiectomy was performed and histological examination confirmed the supposed existence of a LCT. After surgery, the gynecomastia has completely disappeared and hormonal alterations returned to normal.

Testis sparing surgery for steroid unresponsive testicular tumors of the congenital adrenal hyperplasia

The association between testicular tumors/nodules and congenital adrenal hyperplasia (CAH) has been recognized for many years. Tumors are considered to be an aberrant adrenal tissue that has descended with the testes and has become hyperplastic due to ACTH stimulation. The recommended treatment consists of increasing the glucocorticoid dose to suppress ACTH secretions. If the testicular size is not reduced after suppression therapy or a side effect of glucocorticoid dose is noted, surgical intervention should be considered. We diagnosed steroid unresponsive testicular tumors of the CAH in two patients who were treated by testicular sparing tumor enucleation. We believe that testis sparing surgery is the procedure of choice for all patients with testicular adrenal rest tumor, since it maximizes future fertility potential.

Ovarian Leydig cell tumor in a peri-menopausal woman with severe hyperandrogenism and virilization

The authors report a case of Leydig cell tumor in a 46-year-old woman who first presented with severe clinical hyperandrogenism and associated complex medical history. Investigations revealed markedly raised serum concentrations of testosterone (28.3 nmol/l) and free androgen index (54.4), whereas sex hormone binding globulin, random cortisol, androstenedione, 17-hydroxyprogesterone and dehydroepiandrosterone sulphate concentrations were all within the normal range. Transabdominal ultrasound and computed tomography scan of the pelvis and abdomen showed a slightly bulky right ovary, but no other abnormalities. An ovarian source of androgens was suspected and surgery was arranged. Following a three-year history of defaulting appointments due to agoraphobia, she underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and intraoperative selective ovarian venous sampling. Histopathological examination revealed a 2 cm Leydig cell tumor within the right ovary. Successful intraoperative ovarian venous sampling demonstrated significantly elevated testosterone levels (>260 nmol/l) from the right ovarian vein. Hyperandrogenaemia normalized post-operatively. The patient showed significant regression of clinical signs and symptoms, including the anxiety disorder. Clinical presentation, biochemistry and imaging modalities should allow to detect androgen-secreting ovarian tumors, while selective venous sampling should be reserved for patients whom uncertainty remains. The present case confirms that androgen-secreting ovarian tumors represent a diagnostic and therapeutic challenge. They have to be considered in the differential diagnosis of severe hyperandrogenism even in peri-menopausal women. Although selective venous sampling is of diagnostic value, however, its impact on future management should be considered on individual basis.

Intraoperative venous blood sampling to localize a small androgen-producing ovarian tumor

BACKGROUND

Among other causes of virilization, ovarian tumors can be the cause of excessive androgen production. We report the case of a Leydig cell tumor of the ovary where diagnostic attempts to localize the source of hyperandrogenism preoperatively failed owing to relatively small tumor size.

CASE

A 36-year-old woman presented with clinical signs of severe virilization including progressive balding, increased hirsutism, secondary amenorrhea and enlargement of the clitoris. Extensive work-up included endocrinological tests, pelvic ultrasound, magnetic resonance imaging, chromosomal analysis, norcholesterol scintigraphy and selective venous sampling, without direct localization of the source of hyperandrogenism. Persistently high plasma testosterone prompted an explorative laparotomy. Intraoperative selective blood sampling of the ovarian veins and palpation gave evidence of a right ovarian tumor, which was then removed. Histological examination revealed the presence of a pure Leydig cell tumor.

CONCLUSION

Exploratory laparotomy with intraoperative selective blood sampling of the ovarian veins might be a useful approach in patients without accurate preoperative localization of androgen-producing tumors of the ovaries.