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| LETTER TO THE EDITOR |
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| Year : 2015 | Volume
: 52
| Issue : 4 | Page : 529-530 |
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Leydig cell tumor of testis with indeterminate features
R Thambi1, L Pothen1, KM Emmanuel2, A Vijayalakhmi3
1 Department of Pathology, Government Medical College, Kottayam, Kerala, India
2 Surgery, Taluk Hospital, Thodupuzha, Kerala, India
3 Division of Pathology, DDRC, Kottayam, Kerala, India
| Date of Web Publication | 10-Mar-2016 |
Correspondence Address:
R Thambi
Department of Pathology, Government Medical College, Kottayam, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0019-509X.178400
How to cite this article:
Thambi R, Pothen L, Emmanuel K M, Vijayalakhmi A. Leydig cell tumor of testis with indeterminate features. Indian J Cancer 2015;52:529-30 |
Sir,
A 63-year-old man presented with a hard testicular mass of 6 months duration. There were no associated endocrine manifestations or lymphadenopathy. With high suspicion of malignancy, high inguinal orchidectomy was done and specimen was sent for histopathology. Gross examination revealed a testicular mass measuring 9.5 cm × 7 cm × 6 cm. Cut surface was brownish with areas of hemorrhage, necrosis, and calcification [Figure 1]a. Microscopy showed cells arranged in sheets separated by fibrovascular septae [Figure 1]b. Cells were polygonal with moderate to abundant eosinophilic cytoplasm and pleomorphic vesicular nuclei. Occasional cells showed Reinke crystals and lipofuschin pigment [Figure 1]c and [Figure 1]d. Mitosis > 3/10 high power field (HPF), areas of necrosis and calcification were noted. There was no capsular or lymphovascular invasion. A diagnosis of leydig cell tumor with indeterminate histology was made due to the necrosis, frequent mitoses, and large tumor size. | Figure 1: (a) Gross specimen showing normal testis replaced by a tan colored tumor with areas of necrosis. (b) Neoplastic cells arranged in sheets and cords with areas of necrosis (H and E, ×100). (c, d) Polygonal cells with abundant, finely granular, eosinophilic/clear cytoplasm and regular, round to oval nuclei, some with a prominent nucleolus (H and E, ×200, ×400)
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Leydig cell tumors (LCT) are rare neoplasms comprising 1-3% of all testicular tumors. Majority are unilateral with bimodal age involvement, and are hormonally active. They are always benign in children, whereas in adults 10% of cases are malignant.
[1],[2] It can be either pure or mixed with germ cell tumors or other sex cord–stromal tumors. Rare extratesticular sites include, the spermatic cord, adrenal glands, and ovaries.[1] LCTs in pre-pubertal boys present with symptoms of precocious puberty, gynecomastia, and feminization depending on the hormones elaborated. Men between 30 and 60 years are asymptomatic or may present with loss of libido, erectile dysfunction, impotence, and infertility. Serum tumor markers such as α-fetoprotein, β-human chorionic gonadotropin, and placental alkaline phosphatase are normal.
Benign LCT are small (3-5 cm), sharply delineated, solid brown to yellow to gray testicular masses. Microscopy shows tumor cells in nests and sheets separated by delicate fibrovascular septa. Myxoid stroma, microcystic growth pattern, adipocyte differentiation, ossification, and calcification are other histological features. The neoplastic cells are polygonal with abundant cytoplasm and vesicular nuclei with variably prominent nuclei. Other cytological variations are small cells with grooved nuclei and scanty eosinophilic cytoplasm and sarcomatoid cells. Reinke crystals are a useful diagnostic feature. Mitoses are rare and nuclear atypia is absent or minimal. Useful immunomarkers include α-inhibin, calretinin, and Melan-A. Benign LCTs are treated by orchiectomy or testis-sparing surgeries like tumor enucleation with clear margins in boys and young men, to maintain their fertility.
Malignant LCTs are large (>5 cm) replacing the testis with infiltrative margins or extratesticular extension, hemorrhage, and necrosis. Diagnostic criteria for malignant LCT are metastasis and morphological features such as cellular anaplasia, necrosis, extension to the tunica or epididymis, frequent mitoses (>3-5/10HPF) with atypical mitotic figures, lymphovascular invasion, and tumor size of 5 cm or more.[2],[3] DNA aneuploidy, and increased expression of proliferative markers are seen.[1] Malignant LCT metastasize to regional lymphnodes, lung, liver, and bones.[1] Malignant LCTs are treated by orchiectomy with retroperitoneal lymphadenectomy.[3],[4],[5]
Malignant LCT does not respond to chemotherapy and irradiation.
In our case, the tumor was >5 cm, cells showed moderate pleomorphism, increased mitosis (>3/10 HPF), and areas of necrosis favoring malignancy. However, other malignant features such as atypical mitosis, capsular or lymphvascular invasion and metastatasis were absent. Such cases with indeterminate features have malignant potential and needs close follow-up.
This case is presented due to the rarity and to highlight the indeterminate nature of the tumor. Such cases require close follow-up because of the potential for malignant behavior.
| » References | |  |
| 1. | Al-Agha OM, Axiotis CA. An in-depth look at Leydig cell tumor of the testis. Arch Pathol Lab Med 2007;131:311-7.  |
| 2. | Agrawal U, Sharma M, Bhatnagar D, Saxena S. Leydig cell tumor: An unusual presentation. Indian J Pathol Microbiol 2009;52:395-6. [ PUBMED]  |
| 3. | Sengupta S, Chatterjee U, Sarkar K, Chatterjee S, Kundu A. Leydig cell tumor: A report of two cases with unusual presentation. Indian J Pathol Microbiol 2010;53:796-8. [ PUBMED] |
| 4. | Odabas O, Dilek FH, Avanoglu H, Atilla MK, Yilmaz Y, Aydin S. Leydig cell tumor of the testis. East J Med 1998;3:78-9. |
| 5. | Papatsoris AG, Triantafyllidis A, Gekas A, Karamouzis MV, Rosenbaum T. Leydig cell tumor of the testis. New cases and review of the current literature. Tumori 2004;90:422-3. |
[Figure 1]
| This article has been cited by | | 1 |
Management of testicular Leydig cell tumor |
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| Jianguo Zhu,Yun Luan,Haige Li | | Medicine. 2018; 97(25): e11158 | | [Pubmed] | [DOI] | |
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