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Chortis V, Johal NJ, Bancos I, Evans M, Skordilis K, Guest P, Cullen MH, Porfiri E, Arlt W. Mitotane treatment in patients with metastatic testicular Leydig cell tumor associated with severe androgen excess. Eur J Endocrinol 2018; 178:K21-K27. [PMID: 29330226 PMCID: PMC5811932 DOI: 10.1530/eje-17-0542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 12/20/2017] [Accepted: 01/08/2018] [Indexed: 11/11/2022]
Abstract
Mitotane (o,p'DDD) is established in the adjuvant and advanced-stage treatment of adrenocortical carcinoma and counteracts both tumor growth and tumor-related steroid production. Both the adrenal glands and the gonads are steroidogenically active organs and share a common embryogenic origin. Here, we describe the effects of mitotane in two patients with metastatic Leydig cell tumor (LCT) of the testes and associated severe androgen excess (serum testosterone 93 and 88 nmol/L, respectively; male reference range 7-27 nmol/L). Both men suffered from severe restlessness, insomnia and irritability, which they described as intolerable and disrupting normal life activities. Urinary steroid profiling by gas chromatography-mass spectrometry (GC-MS) confirmed excess androgen production and revealed concurrent overproduction of glucocorticoids and glucocorticoid precursors, which under physiological conditions are produced only by the adrenal glands but not by the gonads. In a palliative approach, they were commenced on mitotane, which achieved swift control of the hormone excess and the debilitating clinical symptoms, restoring normal quality of life. GC-MS demonstrated normalization of steroid production and decreased 5α-reductase activity, resulting in decreased androgen activation, and imaging demonstrated disease stabilization for 4-10 months. In conclusion, mitotane can be highly effective in controlling steroid excess in metastatic LCTs, with anti-tumor activity in some cases.
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Affiliation(s)
- Vasileios Chortis
- Institute of Metabolism and Systems ResearchUniversity of Birmingham, Birmingham, UK
- Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Nicholas J Johal
- Institute of Metabolism and Systems ResearchUniversity of Birmingham, Birmingham, UK
| | - Irina Bancos
- Institute of Metabolism and Systems ResearchUniversity of Birmingham, Birmingham, UK
- Division of EndocrinologyMetabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew Evans
- Departments of PathologyQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Kassiani Skordilis
- Departments of PathologyQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Peter Guest
- Radiology and Cancer CentreQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Michael H Cullen
- Cancer CentreQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Emilio Porfiri
- Cancer CentreQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems ResearchUniversity of Birmingham, Birmingham, UK
- Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
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Rove KO, Maroni PD, Cost CR, Fairclough DL, Giannarini G, Harris AK, Schultz KAP, Cost NG. Pathologic Risk Factors for Metastatic Disease in Postpubertal Patients With Clinical Stage I Testicular Stromal Tumors. Urology 2016; 97:138-144. [DOI: 10.1016/j.urology.2016.06.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/02/2016] [Accepted: 06/08/2016] [Indexed: 11/26/2022]
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3
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Management of non-germinal testicular tumors. World J Urol 2009; 27:507-12. [DOI: 10.1007/s00345-009-0403-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Accepted: 03/04/2009] [Indexed: 01/24/2023] Open
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Kim JH, Yang HJ, Yoon JH, Choi MS, Lee DH, Moon KH, Song YS, Park YH. Non-palpable and Asymptomatic Leydig Cell Tumor. Korean J Urol 2006. [DOI: 10.4111/kju.2006.47.2.211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Jae Heon Kim
- Department of Urology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hui Jo Yang
- Department of Urology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jong Hyun Yoon
- Department of Urology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Min Sung Choi
- Department of Pathology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Dong Hwa Lee
- Department of Pathology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Ki Hyuck Moon
- Department of Urology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Yun Seob Song
- Department of Urology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Young Ho Park
- Department of Urology, Soonchunhyang University College of Medicine, Seoul, Korea
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Conkey DS, Howard GCW, Grigor KM, McLaren DB, Kerr GR. Testicular Sex Cord–Stromal Tumours: The Edinburgh Experience 1988–2002, and a Review of the Literature. Clin Oncol (R Coll Radiol) 2005; 17:322-7. [PMID: 16097561 DOI: 10.1016/j.clon.2005.04.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS Sex cord-stromal tumours of the testis are uncommon tumours, accounting for around 5% of testicular neoplasms. Treatment is primarily surgical, with no adjuvant therapy of proven benefit. We present a single-centre experience over a period of 15 years. MATERIALS AND METHODS From 1988 to 2002, 18 patients with a diagnosis of sex cord-stromal tumour were referred to our centre. A retrospective analysis of their case notes was made and a pathological review undertaken. RESULTS Sixteen were Leydig-cell tumours and two were Sertoli cell. For the Leydig-cell tumours, the median age at presentation was 42 years, 50% presented with a testicular mass and 31% with gynaecomastia. Two patients followed a malignant course: one revealing disease dissemination at initial staging, and a second 12 months after potentially curative orchidectomy. Salvage retroperitoneal lymphadenectomy in the latter patient proved unsuccessful. Clinical outcome correlated strongly with the presence of adverse pathological features described previously in the literature. After a median follow-up of 46 months, two patients have developed progressive disease, and two patients have died, one of metastatic Leydig-cell tumour. No patient defined as being of low malignant potential on pathological examination has relapsed outside our review period of 2 years. CONCLUSION We confirm the overall excellent prognosis for most of the patients with sex cord-stromal tumours of the testis. Compared with most previous reports, pathological features seem to predict with reasonable accuracy the risk of malignant behaviour, and can adequately inform the subsequent review policy.
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Affiliation(s)
- D S Conkey
- Urological Oncology Section, Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
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Maeda T, Itoh N, Kobayashi K, Takahashi A, Masumori N, Tsukamoto T. Elevated serum estradiol suggesting recurrence of Leydig cell tumor nine years after radical orchiectomy. Int J Urol 2002; 9:659-61. [PMID: 12534915 DOI: 10.1046/j.1442-2042.2002.00538.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report a case of a Leydig cell tumor that showed retroperitoneal lymph node metastasis 9 years after radical orchiectomy. Elevated serum estradiol (E2) suggested recurrence of the Leydig cell tumor. Retroperitoneal lymph node dissection (RPLND) was performed and the lymph node was proved histopathologically to have a metastatic Leydig cell tumor. After RPLND, serum E2 returned to the normal range. This is the first reported case in which changes in the endocrinological findings were useful as likely tumor markers to detect the recurrence of a Leydig cell tumor.
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Affiliation(s)
- Toshihiro Maeda
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
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Sugimura J, Suzuki Y, Tamura G, Funaki H, Fujioka T, Satodate R. Metachronous development of malignant Leydig cell tumor. Hum Pathol 1997; 28:1318-20. [PMID: 9385943 DOI: 10.1016/s0046-8177(97)90211-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Leydig cell tumor (LCT), a rare testicular tumor, is malignant in only about 10% of the cases. We report the case of a patient with bilateral malignant LCTs that developed metachronously. After undergoing a right inguinal orchiectomy for a malignant LCT at the age of 43 years, the patient was given cisplatin-based chemotherapy for suspected para-aortic lymph node metastasis. Eighteen months after the right orchiectomy, examination of a left testicular biopsy specimen showed a malignant LCT and a left inguinal orchiectomy was performed. Histologically, the initial malignant LCT exhibited a highly pleomorphic appearance with mitotic figures (58/10 HPF), whereas the second malignant LCT showed fewer mitoses (2/10 HPF). The proliferating cell nuclear antigen (PCNA)-labelling index in these tumors also differed (right-sided tumor, 50%; left-sided tumor, 28%). These findings suggest that the malignant LCT in the left testis developed as a second primary rather than as a metastatic tumor. There have been no known similar cases, although three cases of malignant LCT with contralateral metastasis have been reported.
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Affiliation(s)
- J Sugimura
- Department of Pathology, Iwate Medical University School of Medicine, Morioka, Japan
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Sawin PD, VanGilder JC. Spinal cord compression from metastatic Leydig's cell tumor of the testis: case report. Neurosurgery 1996; 38:407-11. [PMID: 8869074 DOI: 10.1097/00006123-199602000-00037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
A case of spinal cord compression from metastatic Leydig's cell tumor of the testis is presented. This 67-year-old man exhibited paraparesis and neurogenic bladder dysfunction secondary to a spinal epidural mass at the T5 level as the initial manifestation of his cancer. Surgical resection was undertaken for tissue diagnosis and spinal cord decompression. The histopathological features of the epidural mass and the excised left testicle were identical, indicative of Leydig's cell carcinoma. The literature is reviewed for previous experience with this exceedingly rare tumor. Unlike most metastatic spinal malignancies, radiation therapy is an ineffectual treatment modality for this tumor. Surgical resection is the only therapeutic option available for amelioration of spinal cord compression.
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Affiliation(s)
- P D Sawin
- Division of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, USA
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Di Tonno F, D'INCà G, Bertoldin R, Vianello F, Di Pietro R, Lavelli D, Guazzieri S. Role of retroperitoneal lymph node dissection in clinical stage I Leydig cell tumours. Urologia 1996. [DOI: 10.1177/039156039606301s20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Leydig Cell Tumours (LCT) account for 3% of all testicular tumours; 10% are malignant and are refractory to radio- and chemotherapy. The role of Retroperitoneal Lymph Node Dissection in clinical stage I LCT is therefore a particularly debated one. From March ‘83 to December ‘95, 10 patients with LCT were subjected to orchiectomy (1 of them bilaterally because of a metachronous tumour). In 10 out of 11 specimens the following pathological features – a) size larger than 50 mm, b) infiltration of spermatic cord, c) lymphatics and veins, d) capsule, e) necrosis, f) cellular pleomorphism, g) numerous mitoses, h) nuclear atypia – were absent. The only patient in which b) and d) were present was subjected to RPLND. After a follow-up ranging from 17 to 157 months all patients are disease-free. Abstention from RPLND in clinical stage I LCT therefore seems the more rational choice when the above- listed pathologic features are absent.
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Affiliation(s)
- F. Di Tonno
- Divisione Urologica - Ospedale Civile - Camposampiero (Padova)
| | - G. D'INCà
- Divisione Urologica - Ospedale Civile - Belluno
| | | | - F. Vianello
- Divisione Urologica - Ospedale Civile - Camposampiero (Padova)
| | - R. Di Pietro
- Servizio di Anatomia Patologica - Ospedale Civile - Camposampiero (Padova)
| | - D. Lavelli
- Divisione Urologica - Ospedale Civile - Camposampiero (Padova)
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Davis JM, Woodroof J, Sadasivan R, Stephens R. Case report: congenital adrenal hyperplasia and malignant Leydig cell tumor. Am J Med Sci 1995; 309:63-5. [PMID: 7825657 DOI: 10.1097/00000441-199501000-00010] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Leydig cell tumors are very rarely seen testicular tumors and can be difficult to distinguish from testicular tumors of the adrenogenital syndrome. Testicular tumors of the adrenogenital syndrome are confined to patients with congenital adrenal hyperplasia. The authors report a case of a patient with malignant Leydig cell tumor and a history of congenital adrenal hyperplasia (adrenogenital syndrome). To the authors' knowledge, this has not been reported previously.
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Affiliation(s)
- J M Davis
- Division of Clinical Oncology, University of Kansas Medical Center, Kansas City 66160-7353
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Palazzo JP, Petersen RO, Young RH, Scully RE. Deoxyribonucleic acid flow cytometry of testicular Leydig cell tumors. J Urol 1994; 152:415-7. [PMID: 8015084 DOI: 10.1016/s0022-5347(17)32752-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
We analyzed by flow cytometry the deoxyribonucleic acid content of 13 paraffin embedded, formalin-fixed Leydig cell tumors of the testis. Of the tumors 10 were clinically benign (9 diploid and 1 aneuploid) and 3 were malignant (aneuploid). The benign aneuploid tumor showed moderate cellular atypia and a low mitotic count (less than 2 per 10 high power fields). Our study suggests that the majority of Leydig cell tumors are diploid and the less common malignant tumors are typically aneuploid, and that deoxyribonucleic acid flow cytometric findings can be useful as a prognostic indicator in these tumors.
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Affiliation(s)
- J P Palazzo
- Department of Pathology, Jefferson Medical College, Philadelphia, Pennsylvania
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12
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Dieckmann KP, Loy V. Response of metastasized sex cord gonadal stromal tumor of the testis to cisplatin-based chemotherapy. J Urol 1994; 151:1024-6. [PMID: 7510344 DOI: 10.1016/s0022-5347(17)35158-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
A 34-year-old man underwent left hemicastration for malignant unclassified sex cord gonadal stromal tumor. At 6 months pulmonary metastases developed and the patient received 3 courses of chemotherapy consisting of cisplatin, bleomycin and etoposide. A residual focus in the right lung was excised and proved to be viable tumor. He then received 2 adjuvant courses of cisplatin, etoposide and ifosfamide. Six months later he was without evidence of disease. A review of the literature revealed 21 previous cases of malignant unclassified sex cord gonadal stromal tumor. Although chemotherapy usually fails in treating Leydig cell tumors our case corroborates 6 previous reports of favorable response to cisplatin-based chemotherapy. This finding suggests that different subtypes of sex cord gonadal stromal tumor respond differently to chemotherapy.
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Affiliation(s)
- K P Dieckmann
- Urologische Klinik, Freie Universität Berlin, Germany
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