Ovarian Leydig Cell Tumor Associated with Recurrent Torsion and Virilization in an Adolescent Patient

Ovarian tumors are rare in children; however, their incidence increases with age. Of these ovarian tumors, Leydig cell tumors are some of the rarest, accounting for less than 0.1% of all ovarian tumors across all ages. Leydig cell tumors predominantly occur in postmenopausal women and are characterized by nodular proliferation of Leydig cells in the ovarian hilum with intracytoplasmic Reinke crystals. These tumors secrete androgens, which can disrupt ovarian function, clinically presenting with abnormal uterine bleeding and virilization. Although they are generally benign, current recommendations are for treatment with a unilateral salpingo-oophorectomy. In adolescents, hyperandrogenism is most commonly caused by polycystic ovarian syndrome (PCOS); however, the differential for hyperandrogenism is broad. We present a case of a 15-year-old girl with a history of primary amenorrhea who presented with a Leydig cell tumor associated with recurrent ovarian torsion and virilization. This case reviews the challenges with diagnosis, management, and future implications of a rare androgen-secreting tumor in young patients.

Two Rare Cases of Paratubal Leydig Cell Nodules: Clinical Relevance and Debated Terminology of a Noteworthy Incidentaloma

Cells with cytologic and immunohistochemical features of Leydig cells are normally present in the ovary and the ovarian hilum, are testosterone-producing, and have been referred to as ovarian hilus cells. Rarely these cells form nests or nodules in extraovarian sites such as the mesovarium or mesosalpinx. Because they are so rare, these nodules can present a diagnostic challenge when first encountered. This report describes 2 such incidental nodules in the mesosalpinx associated with a small paratubal cyst and suggests that the term Leydig cell nodule be preferred over the nonspecific and confusing historical term ovarian hilus cell nest.

Utilization of NKX3.1, P501S, Prostate-Specific Antigen, and Steroidogenic Factor 1 to Distinguish Malignant Leydig Cell Tumor From Metastatic Prostatic Adenocarcinoma to the Testis

CONTEXT.—

A recent study demonstrated that NKX3.1-positive staining can uncommonly be seen in testicular Sertoli cell tumors (1 of 4 cases). Also, it was reported that 2 of 3 Leydig cell tumors of the testis showed diffuse cytoplasmic staining for P501S, although it was unclear whether it was specific granular staining that defines true positivity. However, Sertoli cell tumors do not typically pose a diagnostic dilemma with metastatic prostate carcinoma to the testis. In contrast, malignant Leydig cell tumors, which are exceedingly rare, can closely resemble Gleason score 5 + 5 = 10 prostatic adenocarcinoma metastatic to the testis.

OBJECTIVE.—

To evaluate the expression of prostate markers in malignant Leydig cell tumors and steroidogenic factor 1 (SF-1) in high-grade prostate adenocarcinoma, as no data are currently published on these topics.

DESIGN.—

Fifteen cases of malignant Leydig cell tumor were collected from 2 large genitourinary pathology consult services in the United States from 1991 to 2019.

RESULTS.—

All 15 cases were negative immunohistochemically for NKX3.1, and all 9 with available additional material were negative for prostate-specific antigen and P501S and positive for SF-1. SF-1 was negative immunohistochemically in a tissue microarray with cases of high-grade prostatic adenocarcinoma.

CONCLUSIONS.—

The diagnosis of malignant Leydig cell tumor and its distinction from metastatic adenocarcinoma to the testis can be made immunohistochemically on the basis of SF-1 positivity and negativity for NKX3.1.

Hyperandrogenism due to ovarian Leydig cell tumour presenting with polycythaemia

A postmenopausal woman in her 60s was referred due to an elevated haemoglobin value found during her annual check-up. On physical examination, characteristic features of hyperandrogenism were observed which were not earlier mentioned. Laboratory investigations revealed polycythaemia accompanied by a normal erythropoietin and a negative analysis for JAK2-V617F mutation. A disproportionally and markedly elevated testosterone in combination with normal levels of adrenal androgens raised the suspicion of an ovarian source. CT scan showed nodular hyperdense lesions in both ovaries. A bilateral oophorectomy was performed and histological evaluation unfolded a Leydig cell ovarian tumour. Testosterone levels and haematological parameters normalised after surgery. Polycythaemia secondary to hyperandrogenism in postmenopausal women is an extremely rare condition and patients should be carefully analysed for the presence of androgen-secreting neoplasms. Diagnosis of the underlying pathology requires careful history, physical examination and comprehensive investigation. Treatment for this condition is surgery and resolves polycythaemia.

Occult symptomatic bilateral pure Leydig cell tumors in a postmenopausal woman: a case report

BACKGROUND

Pure Leydig cell tumors (LCTs) represent 0.1% of ovarian masses. Postmenopausal patients typically present with virilization. Although LCTs can be challenging to locate on conventional imaging, positron emission tomography (PET) has been demonstrated to be effective.

CASE

A 64-year-old postmenopausal woman presented with alopecia, facial hirsutism, and clitoromegaly. Laboratory findings included elevated testosterone and androstenedione. Ultrasound, computed tomography, and magnetic resonance imaging showed no adnexal masses. PET did not demonstrate ovarian fludeoxyglucose-avidity. Histopathology after bilateral salpingo-oophorectomy revealed bilateral Leydig cell tumors. Her testosterone normalized 2 weeks postoperatively.

CONCLUSION

We describe the occult, symptomatic, bilateral ovarian Leydig cell tumors, an occurrence that has not been described in the literature. Virilizing tumors must be considered in patients with evidence of hyperandrogenism, even without pelvic masses on imaging.

New-onset hirsutism

This postmenopausal patient developed hirsutism following a surgical procedure. Thorough lab work directed us to the unusual cause.

Adolescent Renomedullary Interstitial Cell Tumor: A Case Report

A 14-year-old boy presented with painless gross hematuria after a blunt trauma to his right lumbar region. Abdominal ultrasonography and abdominal computerized tomography revealed that the right kidney was hydronephrotic; contrast material delineated a hematoma inside the kidney. The patient underwent a right simple nephrectomy and after histopathological examination was found to have a renomedullary interstitial cell tumor of the right kidney. This tumor is common in patients older than 50 years, whereas our patient was very young. The diagnosis of this small tumor is not possible by conventional radiological techniques and histopathological examination is mandatory for its diagnosis.

Malignant Leydig cell tumor in dogs: two cases and a review of the literature

Malignant Leydig cell tumor (MLCT) is a rare testicular tumor in dogs. We report herein 2 dogs with MLCT and cutaneous metastasis. Grossly, marked enlargement and distortion of the involved testes were noted; on cut surface, the parenchyma was completely replaced by neoplastic tissue. In addition, these tumors had extensive necrosis and hemorrhage. Case 1 had a rapidly growing cutaneous mass in the left angle of the mouth; the lesion was well-circumscribed and had an indistinct lobular pattern. Case 2 had multiple cutaneous masses in the dorsal neck region, the thoracic back region, and the right hindlimb. Microscopically, the tumor lobules were composed of oval-to-polyhedral cells with eosinophilic cytoplasm and resembled testicular tumors. By immunohistochemistry, the neoplastic cells in both the testicular and cutaneous tumors were positive for inhibin-alpha and melan A. The mitotic counts of the primary tumors from cases 1 and 2 were 21 and 11 per 10 high-power fields, respectively. Based on these findings, the cases were diagnosed as MLCT with cutaneous metastasis. Ki-67 expression in the neoplastic cells of the 2 cases was higher than in benign Leydig cell tumors. Our findings may be helpful for the diagnosis of canine MLCT.

Malignant Leydig Cell Tumor in Elderly Complete Androgen Insensitivity Patient: A Case Report

There are various cause of Primary amenorrhea in phenotypically females such as, complete androgen insensitivity syndrome, pure gonadal dysgenesis, 17b-hydroxysteroid dehydrogenase deficiency, or mixed gonadal dysgenesis. Primary amenorrhea in a phenotypically female is commonly encountered in Androgen insensitivity syndrome. In patients of AIS with intra-abdominal testis there is high chances of developing testicular tumour, among them Sertoli cell tumour and seminoma being the most common types. Leydig cell tumour in AIS is very rare and malignant leydig cell tumour is even further rarer. There are few case reported in the literatures of malignant leydig cell tumour with complete androgen insensitivity. Here we are reporting a case of 65 years married elderly patient with malignant leydig cell tumour with CAIS.

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.

Management of testicular Leydig cell tumor: A case report

RATIONALE

Testicular Leydig cell tumor (LCT) is a rare neoplasm. It commonly presents as a painless testicular mass with or without endocrine changes. Histological and immunohistochemical examination play important roles in differentiating LCT from testicular germ cell tumors.

PATIENT CONCERNS

We highlight the imaging phenotype, as well as the pathological findings of a case of LCT in a 62-year-old male.

DIAGNOSES

Preoperative noncontrast CT scan of the abdomen revealed a 7.0 × 6.4 × 5.3 cm oval mass with heterogeneous density, located in the right testis. Pelvic noncontrast MRI showed a heterogeneous mass on T1-weighted and T2-weighted images. The solid part of the tumor exhibited high signal on the diffusion-weighted imaging, and an obvious enhancement on the contrast-enhanced MR imaging. Ultrasonography examination demonstrated a large mixed echogenic space occupying lesion involving the whole right testis with multiple cystic areas and increased vascularity. This patient underwent radical orchiectomy. The pathologic diagnosis was LCT.

INTERVENTIONS

This patient underwent operative resection of the tumor. Due to the negative resection margins and absence of distant metastases, the patient did not receive additional radiotherapy or chemotherapy.

OUTCOMES

Four months after the surgery, the follow-up CT-scan did not reveal any local recurrence and distant metastases.

LESSONS

This case improves our ability to detect and diagnose LCT by summarizing its imaging characteristics as well as reviewing the literature. Additionally, we described the state-of-the-art management of the management of this rare tumor.

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.

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.

Leydig cell tumor in the post-menopausal woman: case report and literature review

Leydig cell tumors of the ovary account for less than 0.1% of all ovarian tumors (1). We present two cases in which patients had markedly elevated serum testosterone levels and frank hirsutism. Both cases revealed right ovarian Leydig cell tumors upon oophorectomy with post-surgical resolution of hypertestosteronemia. While rare and difficult to diagnose, androgen secreting tumors should be suspected in women with hyperandrogenism and hirsutism, especially in the postmenopausal population.

Abundance of DLK1, differential expression of CYP11B1, CYP21A2 and MC2R, and lack of INSL3 distinguish testicular adrenal rest tumours from Leydig cell tumours

OBJECTIVE

Testicular adrenal rest tumours (TARTs) are a common finding in patients with congenital adrenal hyperplasia (CAH). These tumours constitute a diagnostic and management conundrum and may lead to infertility. TART cells share many functional and morphological similarities with Leydig cells (LCs), and masses consisting of such cells are occasionally misclassified as malignant testicular tumours, which may lead to erroneous orchiectomy in these patients.

DESIGN

In this study, we aimed to investigate the potential of LC developmental markers and adrenal steroidogenic markers in the differential diagnosis of TARTs and malignant LC tumours (LCTs).

METHODS

We investigated mRNA and protein expression of testicular steroidogenic enzymes; CYP11A1 and HSD3B1/2, markers of adrenal steroidogenesis; CYP11B1, CYP21A2 and ACTH receptor/melanocortin 2 receptor (MC2R), and markers of LC maturation; and delta-like 1 homolog (DLK1) and insulin-like 3 (INSL3) in testicular biopsies with TART, orchiectomy specimens with LCTs and samples from human fetal adrenals.

RESULTS

Expression of testicular steroidogenic enzymes was observed in all specimens. All investigated adrenal steroidogenic markers were expressed in TART, and weak reactions for CYP11B1 and MC2R were observed at the protein level in LTCs. TART and fetal adrenals had identical expression profiles. DLK1 was highly expressed and INSL3 not detectable in TART, whereas INSL3 was highly expressed in LCTs.

CONCLUSIONS

The similar expression profiles in TART and fetal adrenals as well as the presence of classical markers of adrenal steroidogenesis lend support to the hypothesis that TART develops from a displaced adrenal cell type. Malignant LCTs seem to have lost DLK1 expression and do not resemble immature LCs. The different expression pattern of DLK1, INSL3 and most adrenocortical markers adds to the elucidation of the histogenesis of testicular interstitial tumours and may facilitate histopathological diagnosis.

Woman with virilizing congenital adrenal hyperplasia and Leydig cell tumor of the ovary

We report the case of a 36-year-old woman with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, and corticosteroid replacement therapy since birth. She manifested persistent virilization and high testosterone levels that were attributed to nonadherence to medical treatment. The patient was referred to our gender unit for genitoplastic surgery. We recommended the patient for left oophorectomy after detecting an ovarian mass. Pathologic findings confirmed an ovarian hilus cell tumor. Testosterone levels fell back to normal and masculinization disappeared but ACTH remained elevated. This case represents a very rare type of primary ovarian tumor that must be considered in persistent virilizing symptoms in women with CAH.

Hyperandrogenism in post-menopausal women: a diagnosis challenge

A 79-year-old woman, presented with increased hair growth in the chin and the upper lip but no in other androgen-dependent areas of her body. Hormonal evaluation showed markedly elevated serum testosterone level (>1.7 ng/ml) and normal DHEA-S, androstenedione, 17-hydroxyprogesterone, cortisol and TSH levels. The diagnosis of probable pure testosterone secreting tumor was made. Transvaginal ultrasound and magnetic resonance image revealed a 16 mm × 12 mm nodular formation indicative of an atypical adenoma in the left adrenal gland and a tube-shaped, fluid-filled, thin-walled image measuring 28 mm × 14 mm suggestive of a hydrosalpinx in the right ovary. Differential diagnosis between the coexistence of an androgen-producing ovarian tumor (occult) associated with a finding of an adrenal image (Incidentaloma) or an adrenal tumor secreting testosterone only was done. Since cortisol levels went down, but total testosterone inhibition did not occur after suppression with dexamethasone. An ovarian androgen secreting tumour was suspected and surgery was performed. Histological examination showed a Leydig cells hyperplasia. After the operation testosterone returned to normal with regression of clinical symptoms.

A Leydig cell tumor of the ovary resulting in extreme hyperandrogenism, erythrocytosis, and recurrent pulmonary embolism

CONTEXT

Secondary erythrocytosis due to androgens is most commonly seen in the context of T replacement therapy in men. Leydig cell ovarian tumors are a rare cause of virilization, erythrocytosis, and thromboembolism.

PATIENT CASE

We describe the case of a 55-year-old postmenopausal woman who presented with a 3-year history of frontal balding and virilization and a 5-year history of obstructive sleep apnea. She had not experienced significant alteration in libido or mood. Menstruation had ceased at age 46. She had a history of recurrent pulmonary embolism and unexplained secondary erythrocytosis. Past hematological investigations had not revealed any evidence of malignancy or thrombophilia, and the JAK2 mutation was negative. The serum erythropoietin was mildly elevated at 20.3 mIU/mL (normal range, 3.6-16.6 mIU/mL). The serum T was initially reported (by immunoassays) as >1600 ng/dL (>55 nmol/L). Similarly, serum androstenedione (>1000 ng/dL; >35 nmol/L), estradiol (169 pg/mL; 621 pmol/L), and dehydroepiandrosterone sulfate (348 μg/dL; 9.4 μmol/L) were all elevated for a postmenopausal woman. Repeat analysis of the serum T by mass spectrometry showed an extremely elevated level of 4270 ng/dL (148 nmol/L). Computed tomography scan revealed a 5.0-cm right ovarian tumor. After surgical removal of an ovarian Leydig cell tumor, her virilization, erythrocytosis, and sleep apnea resolved.

CONCLUSION

Hyperandrogenism in women should be considered as a rare but important cause of erythrocytosis, recurrent thromboembolism, and sleep apnea. The diagnosis of hyperandrogenism requires a careful history and physical examination because in postmenopausal women, menstrual disturbance does not occur and cosmetic measures may mask overt clinical features.

Virilization due to androgen hypersecretion in a patient with ovarian leydig cell tumor: diagnostic and psychosocial implications

Virilization due to hyperandrogenism in women causes male signs and symptoms such as swelling of the clitoris, deepening of the voice, facial hair and increase in body hair. Virilization is caused by less than 0.5% of all ovarian tumors. Here we report a case of virilizing Leydig cell tumor of the left ovary in a 36 year old woman. Misinterpretation of symptoms, conflicting medical information and advice from previous doctors had confused the patient. We performed a diagnostic evaluation including clinical, hormonal parameters, imaging, anatomical pathology examinations, and psychological assessment. Blood analysis showed a high testosterone level. The presence of an ovarian tumor was confirmed by laparoscopy. Since the patient refused ovariectomy, a biopsy of the left ovary was performed. Pathology showed a Leydig cell tumor without histological signs of malignancy. In spite of extensive explanation and psychological counseling, cultural barriers prevented appropriate treatment. An ovarian Leydig cell tumor should always be considered for a woman in the reproductive age with symptoms of virilization. The diagnosis is suspected on the basis of an ovarian mass on examination and further investigation and should be proven by biopsy.

Leydig cell hyperplasia and Leydig cell tumour in postmenopausal women: report of two cases

Leydig cell hyperplasia and Leydig cell tumours of the ovary are rare. We present two cases in which patients had increased blood levels of testosterone and frank hirsutism. Imaging showed minimal abnormalities. After adrenal disease had been ruled out, they underwent a bilateral oophorectomy. One case showed a Leydig cell hyperplasia, the other a Leydig cell tumour. An androgen producing tumour should be excluded in every woman with evidence of hirsutism or frank virilization and markedly elevated testosterone levels. Adrenal disease with androgen hypersecretion can be suspected by detailed clinical, laboratory and radiologic imaging. Although DHEAS has a good sensitivity in the detection of adrenal origin of hyperandrogenism (and hence a good negative predictive value) it is not specific (specificity ranging from 85 to 98%). Imaging of the ovaries can be helpful but does not rule out ovarian disease if normal. Indeed, diffuse stromal Leydig cell hyperplasia and Leydig cell tumours (usually small) may escape imaging and in some cases diagnosis can only be made on pathology. As these clinical entities represent a diagnostic and therapeutic challenge, oophorectomy should be considered in postmenopausal women with hirsutism and elevated testosterone levels, after the exclusion of adrenal causes. The procedure is relatively safe and effective. Follow-up remains indicated.

[Diagnostic value of MRI in testicular tumor]

OBJECTIVE

To study the MRI manifestation of testicular tumor and the value of MRI in the diagnosis of the disease.

METHODS

We retrospectively analyzed 23 cases of pathologically confirmed testicular tumor, and observed the morphological characteristics, signals and surrounding conditions of the tumor using plain and enhanced MRI scanning.

RESULTS

Of the 23 cases, seminoma was identified in 7, mixed germinoma in 3, teratoma in 3, endodermal sinus tumor in 2, epidermoid in 1, Leydig cell tumor in 1, leucoma in 1, nonspecific inflammatory mass in 3, and tuberculosis in 2. MRI revealed the precise locations and specific characteristics of

CONCLUSION

Based on MRI findings and clinical manifestation, most testicular tumors can be diagnosed correctly.

A premenopausal woman with virilization secondary to an ovarian Leydig cell tumor

BACKGROUND

A 33-year-old woman presented to an endocrinology clinic with a 5-year history of secondary amenorrhea. 2 years before presentation, she had noticed progressively worsening signs of virilization.

INVESTIGATIONS

Measurement of levels of serum free and total testosterone, androstenedione, dehydroepiandrosterone sulfate and gonadotropins; transvaginal ultrasonography, abdominal and pelvic MRI and (18)F-fluorodeoxyglucose PET imaging.

DIAGNOSIS

Virilization secondary to an ovarian Leydig cell tumor.

MANAGEMENT

The patient underwent a left salpingo-oophorectomy that confirmed the diagnosis of a unilateral Leydig cell tumor. Complete normalization of androgens and gonadotropin levels was achieved after surgery.

Unilateral asymptomatic testis enlargement in children and adolescents

In literature a well codified definition of unilateral asymptomatic testis enlargement does not exist. Therefore in these cases the pediatrician or adolescentologist will have to make a clinical and diagnostic evaluation in order to exclude: a) an enlarged testis secondary to tumors, surgery, or endocrinological diseases; b) a small testis due to a previous (ex. cryptorchidism) or current disease (e.g. varicocele).The presence of a mild difference in testis volumes during puberty is not at all rare. This situation may be due to the technique used for evaluation of testis volume or secondary to a varicocele. The identification of variants of testis enlargement is important, because, while on one hand there are conditions without clinical relevance, on the other hand, there are diseases that require early diagnosis and immediate treatment. The Authors report a brief review of the literature and their own clinical experience. 14 patients with unilateral testis enlargement were observed. At the first examination, mean age was 12.3±1.2 years and the volume of the enlarged testis varied between 4 ml and 20 ml (mean volume 10±4 ml) versus 1.5 ml and 10 ml (mean volume 5±2 ml) of the contralateral testis. In 75% of cases the right testis was affected. During the ten year follow-up, the volume of the enlarged testis never exceeded 25 ml and progressive reduction of the difference between the two testes was demonstrated. Therefore, they propose another clinical condition defined as transitory unilateral testis enlargement of puberty.

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.