Focal lobular spermatogenesis and pubertal acceleration associated with ipsilateral Leydig cell hyperplasia

Nodular Maturation of the Testis: A Non-neoplastic Lesion of Boys That May Present as a Mass on Clinical and Ultrasound Examination

We have encountered a lesion of the pediatric testis, termed "nodular maturation," that clinically mimics a testicular neoplasm causing ultrasound abnormalities that may lead to surgical excision. To our knowledge, it has only been described anecdotally in textbooks without a series or description in the literature. We, therefore, report 8 cases in pediatric patients emphasizing the clinical presentation, ultrasound findings, histologic features, and clinical follow-up information. Patients ranged in age from 5 to 11 years (mean: 7.9 y). Precocious puberty was identified in 1 patient as isolated penile enlargement without other signs; another had a history of McCune-Albright syndrome, but did not have signs of precocious puberty; others had no clinical manifestations. All patients had testicular abnormalities on ultrasound; 6 had a discrete lesion and 2 showed diffuse testicular enlargement. In the 6 cases with available data, mean size of the lesion on ultrasound was 0.9 cm (range: 0.4 to 1.7 cm). In the 3 cases for which macroscopic descriptions were available, no gross abnormalities were noted in the testicular parenchyma, despite the ultrasound findings. Histologically, nodular maturation occurred as a zone of more mature testicular parenchyma having larger, lumen-bearing seminiferous tubules that contrasted with the smaller, immature cords of the remaining parenchyma. The mature tubules showed germ cell maturation (to the level of late spermatids/spermatozoa in 6 cases), mature Sertoli cells, and, in 4 cases, admixed nodules of mature Leydig cells. Of the 6 patients with available follow-up information, none developed a testicular neoplasm. Given its ability to cause a lesion on ultrasound leading to surgical intervention, pathologists, radiologists, and urologists should be aware of nodular maturation.

Bilateral testicular Leydig cell hyperplasia presented incidentally: A case report

Introduction

Leydig cell hyperplasia or tumor represents less than 3% of all testicular tumors. It can be defined as an increase in the size and number of Leydig cell within the testicles. These cells are responsible for the production of testosterone in human males.

Case presentation

Our patient is a forty-eight-year-old male presented with erectile dysfunction and decreased libido for the past six months. Ultrasound of the scrotum show bilateral hypoechoic testicular masses larger on the left size thus left orchidectomy was performed. Histopathology confirmed our diagnosis.

Discussion

Leydig cell hyperplasia (LCH) is a rare and mostly benign entity that affects both children and adults. In adults, it might be associated with variety of condition including Klinefelter's syndrome, exogenous human chorionic gonadotropin (hCG) therapy, and many others but it mostly occurs idiopathically. Scrotal ultrasound and tumor markers can be used to diagnose most of the patients with LCH.

Conclusion

LCH should be differentiated from Leydig cell tumor to avoid unnecessary and sometimes harmful intervention in the future.

•

Leydig cell hyperplasia or tumor represents less than 3% of all testicular tumors.

•

Leydig cell hyperplasia (LCH) is a rare and mostly benign entity that affects both children and adults.

•

LCH should be differentiated from Leydig cell tumor (LCT) to avoid unnecessary or harmful interventions.

Spermatogenesis in pre-pubertal boys with Leydig cell neoplasms suggests paracrine stimulation by testosterone

INTRODUCTION

Pediatric Leydig cell tumors (LCTs) represent approximately 4% of pre-pubertal testicular tumors and are known to cause precocious puberty secondary to testosterone production. While gonadotropins and testosterone are known to initiate spermatogenesis beginning in puberty, it is yet to be determined if a similar phenomenon is triggered by isolated testosterone production in prepubescent boys.

OBJECTIVE

To determine if testicular pathology in pre-pubertal pediatric patients with LCTs exhibit spermatogenesis secondary to paracrine testosterone stimulation.

STUDY DESIGN

We reviewed patients who underwent orchiectomy for a testicular tumor from 2003-17. We included patients with LCTs and compared them to children with non-LCT pathology (teratomas and epidermoid cysts). We excluded other pathologies and tumors in pubertal patients. Data were collected on the presence of spermatogenesis on pathology, tumor markers and serum hormone results.

RESULTS

Orchiectomy for testicular tumors were completed in 66 patients, of which 20 were included in the non-LCT group and 9 in the LCT group. Two of the 9 LCT patients had bilateral pathology. Age at presentation was 6.3 ± 5.8 years for the non-LCT group vs. 8.4 ± 1.6 years for LCTs (p = 0.261). Spermatogenesis was detected in 7 (64%) LCT specimens vs 2 (10%) non-LCT specimens (p = 0.002). Age of the spermatogenesis patients in the non-LCT group (11.08 ± 2.5 years) was older than LCT ones (8.3 ± 2.0 years), suggesting that spermatogenesis in the non-LCT group may be due to early pubertal development. The summary figure demonstrates spermatogenesis identified in a pre-pubertal LCT patient.

DISCUSSION

In this study, pre-pubertal males with LCTs were identified to have pathology evidence of spermatogenesis compared to controls with non-LCT pathology. This represents the first study assessing paracrine testosterone effects on spermatogenesis in pre-pubertal patients with LCTs. In contrast, adult literature on LCTs primarily report on resulting concerns for fertility, gynecomastia and testicular atrophy.

CONCLUSION

LCTs can induce spermatogenesis in prepubertal patients. This reinforces the hypothesis that paracrine testosterone signaling plays a role in spermatogenesis. Our findings could help explore novel fertility preservation opportunities in children.

Characteristics of testicular tumors in prepubertal children (age 5-12 years)

INTRODUCTION

Testicular tumors in children have two peaks with different types of tumors; in the first 4 years of life a third to half are benign with increased risk of malignancy during puberty. The pathology of testicular tumors between these peaks, at the age of 5-12 years, is not known. We hypothesized that because of the low level of testosterone at this time, the incidence of malignant tumors is very low.

OBJECTIVE

To compare malignancy risk of primary testicular tumors in children in the prepubertal period (5-12 years) compared with younger (0-4 years) and pubertal (13-18 years) children.

STUDY DESIGN

We retrospectively (2002-2016) identified patients <18 years with surgery for primary testicular tumor. Patients with testicular tumor risk were excluded. Ultrasound studies were reviewed for contralateral testis volume, tumor morphology, and tumor maximal diameter, for three age groups: 0-4, 5-12, and 13-18 years. The Freeman-Halton extension of the Fisher exact probability test was adopted for categorical outcomes, and one-way ANOVA for continuous outcomes.

RESULTS

Fifty-two patients (mean age 11.0 years, range 6 days-18 years) were identified. Malignant tumor prevalence significantly differed (p < 0.01) among age groups (Fig).: 0-4 (72.7%, 8/11), 5-12 (0%, 0/16), and 13-18 years (44.0%, 11/25). The most common tumor types in 5-12 years were epidermoid cyst (31.3%, 5/16) and tumor mimics (37.5%, 6/16). Prevalence of cystic tumors in 5-12 year olds was not significantly different compared with other age groups. Contralateral testicular volume >4 mL (pubertal surge) significantly (p < 0.01) differed among groups: 0-4 years (0/11), 5-12 years (3/16), and 13-18 years (19/20). In children aged 13-18 years the mean tumor maximal diameter (29.8 ± 4.4 mm) was significantly larger (p < 0.01) compared with children 5-12 years (9.3 ± 5.5 mm) and all malignant tumors had contralateral testicular volume >4 mL.

DISCUSSION

We found that preadolescent children between the ages of 5 and 12 years have distinctive characteristics compared with the other age groups. Most importantly, no malignant testicular tumors were found in this age group. About a third of the children presented with an incidental testicular mass. The testicular tumors were significantly smaller (9.3 ± 6.7 mm) compared with those in children aged 13-18 years (29.8 ± 4.4 mm). There were limitations because of the retrospective nature of the study.

CONCLUSION

We found no malignant testicular tumors in children aged 5-12 years with no risk factors and prior to pubertal surge. Our study suggests use of more conservative treatment in this group of patients.

Leydig cell hyperplasia in children: Case series and review

INTRODUCTION

Leydig cell hyperplasia (LCH) and Leydig cell tumours (LCTs) in children are rare, typically presenting with precocious puberty. Previously, orchidectomy was the routine management; however, more recently, testis-sparing surgery has been performed with good results. We present a series of unusual presentations of LCH, raising new management questions, and a review of the literature regarding LCH and LCT in children.

STUDY DESIGN

We performed a literature search using Ovid Medline, PubMed, and Google Scholar, producing 456 articles. We reviewed all case reports and series containing paediatric patients, and relevant review articles.

RESULTS

We report three cases of LCH, two of which were incidental findings. All three cases underwent testis-sparing surgery. In the literature there were seven cases of LCH and 101 cases of LCT in prepubertal children. The most common presentation was with precocious puberty. Three cases of LCH and more than two-thirds of LCTs were managed with orchidectomy and overall only 11% of the cases underwent testes-sparing surgery (24% did not specify operative management). There were no reports of recurrence or malignancy.

DISCUSSION

Our case series presents three new clinical presentations of LCH that have not previously been reported in the literature: one of incomplete precocious puberty and two with incidental findings on ultrasound in asymptomatic children. Historically, children with the classic presentation of precocious puberty and a testicular lesion have been managed with orchidectomy. Nowadays, many clinicians advocate testes-sparing surgery given there have been no cases of malignancy. In children with no clinical or biochemical signs of precocious puberty, lesions identified on ultrasound can be safely monitored for a period of time. However, if the lesion does not regress, excisional biopsy is recommended to establish the diagnosis, ideally before the onset of puberty.

CONCLUSION

Leydig cell hyperplasia and tumours in pre-pubertal children are benign. Testes-sparing surgery with regular follow-up appears to be safe management.

Paracrine Effects of Leydig Cell Nodular Hyperplasia, Two Case Reports: A Neglected Phenomenon

Leydig cell nodular hyperplasia (LCNH) is a lesion that is less characterized than the familiar Leydig cell tumors. The paracrine effects of these lesions on adjacent gonadal stroma have not been widely documented. We present two cases of precocious puberty in pre-pubertal boys found to have a single LCNH with adjacent focal maturation of the seminiferous tubules. Blood tests showed elevated serum testosterone and dehydroepiandrosterone (DHEAS). Ultrasound revealed unilateral testicular enlargement with irregular echogenicity. Radical orchiectomy was performed. Histologically Leydig cell nodular proliferation without destruction of surrounding tubules was seen. Mature seminiferous tubules undergoing spermatogenesis were noted adjacent to the lesion, while away from the lesion seminiferous tubules were as expected in pre-pubescent boys. These cases emphasize the potential presence of both paracrine and endocrine effects in Leydig cell nodular hyperplasia. However, instances of the endocrine effects of hyperplastic Leydig cell lesions are more widely reported than the paracrine effects.

Tumeur testiculaire bilatérale synchrone à cellules de Leydig: à propos d’un cas

Les tumeurs testiculaires à cellules de Leydig sont rares, elles représentent entre 1 et 3 % de l’ensemble des tumeurs testiculaires. L’atteinte bilatérale synchrone est exceptionnelle. Découverte dans 20 % des cas lors de la première décennie, elle peut être retrouvée dans toutes les tranches d’âge, le diagnostic étant effectué après 50 ans dans 25 % des cas. Le diagnostic est classiquement suspecté devant une anomalie sécrétoire intéressant les hormones sexuelles et seule l’histologie confirme le diagnostic. Nous rapportons le cas d’un patient âgé de 25 ans qui présente une tumeur bilatérale synchrone à cellules de Leydig traité par orchidectomie unilatérale et tumorectomie controlatérale.

Androgen-regulated transcripts in the neonatal mouse testis as determined through microarray analysis

Androgens are required for normal spermatogenesis in mammalian testes. These hormones directly regulate testicular somatic cells that, in turn, support germ cell differentiation. However, the identity of genes under androgen regulation in the testis are not well known. In the present study, neonatal male mice (8 days postpartum) treated by testosterone propionate (TP) were used to study androgen action in the testis as evidenced by alterations in gene expression. Mice were treated with 0.5 mg of TP or dihydrotestosterone (DHT) or vehicle (oil), and testes were harvested 4, 8, and 16 h after treatment. Global gene expression was monitored by microarray analysis. Real-time reverse transcription-polymerase chain reaction was performed to confirm the microarray results. The methodology was verified by confirming the presence of previously characterized TP-regulated genes, including Pem in Sertoli cells and Cyp17a1 in Leydig cells. No significant differences in gene expression were found between TP- and DHT-treated samples. Microarray analysis identified 141, 119, and 109 up-regulated genes at 4, 8 and 16 h after TP treatment, respectively, and 83, 99, and 111 down-regulated genes at the same corresponding time points. The androgen regulation of the selected gene was verified further using testes from flutamide-treated adult mice and isolated Sertoli cells in culture. The data generated in the present study may serve as a foundation for hypothesis-driven research and provide insights regarding gene networks and pathways under androgen control in the testis.

[Bilateral Leydig cell tumor of the test: a case report]

Testicular Leydig cell tumours are uncommon. Bilateral synchronous lesions are exceptional. They cause isosexual pseudo precocious puberty in childhood. The histological diagnosis of malignancy is sometimes difficult to establish and it can be made retrospectively when lymph nodes involvement or visceral metastasis appear in the follow-up. We report a case of a 9 year-old boy presenting bilateral Leydig cell tumour of the testis treated by bilateral radical orchiectomy who developed 2 years after the intervention a pulmonary metastasis.