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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 52  |  Issue : 3  |  Page : 395-396
Leydig cell tumor: An unusual presentation


1 Institute of Pathology, ICMR, New Delhi, India
2 Safdarjang Hospital, New Delhi, India

Click here for correspondence address and email

Date of Web Publication12-Aug-2009
 

   Abstract 

Leydig cell tumor is a benign tumor of the testis and malignant transformation, if present, is rare. The case presented here showed certain features of malignancy but no infiltration beyond the capsule or metastasis. The case could not be labeled as benign or malignant and patient is on follow-up. Differential diagnosis and clinical implications of a case in the borderline zone are discussed.

Keywords: Malignancy, testis, leydig cell tumor

How to cite this article:
Agrawal U, Sharma M, Bhatnagar D, Saxena S. Leydig cell tumor: An unusual presentation. Indian J Pathol Microbiol 2009;52:395-6

How to cite this URL:
Agrawal U, Sharma M, Bhatnagar D, Saxena S. Leydig cell tumor: An unusual presentation. Indian J Pathol Microbiol [serial online] 2009 [cited 2019 Nov 19];52:395-6. Available from: http://www.ijpmonline.org/text.asp?2009/52/3/395/55005



   Introduction Top


Leydig cell tumor is a testicular tumor with a low incidence accounting for 1-3% of testicular neoplasms. It manifests in the preadolescent or in the older people. It is a non-germ cell tumor of the testis and is included in the group of specialized gonadal stromal neoplasms. The frequent clinical presentation is that of a testicular nodule with or without endocrine manifestations. [1] Features associated with malignant behavior are the age, size, infiltration beyond the capsule and metastasis. A case of Leydig cell tumor with some unusual features is presented here.


   Case Report Top


A 33-year-old man presented to the surgical outpatient department with a left testicular mass present for four months. A detailed clinical history and thorough examination revealed no abnormality. He was advised surgery. High inguinal orchidectomy was performed and the specimen submitted for histopathological examination.

Morphology

Grossly, the tumor was 14 7 cm in size and cut section revealed a brown tumor replacing the testicular tissue but not appearing to extend beyond the capsule. Areas of chalky white calcifications and necrotic areas were present.

Microscopic examination revealed total replacement of testicular tissue with a tumor composed of sheets of cells separated into lobules by thin fibrous septa and infiltrating the adjacent stroma. The cells had acidophilic to vacuolated cytoplasm and well-defined cytoplasmic membrane. Occasional cells with large nuclei and multinucleated cells were also evident. The nucleus was vesicular and occasionally grooved. Nuclear pleomorphism was moderate. Focal areas of necrosis and vast areas of calcification were seen [Figure 1]. Mitotic activity, though present, was not intense [[Figure 1] inset].The tumor did not extend beyond the capsule.

Immunohistochemistry revealed intense positivity of the tumor cells for Vimentin and Calretinin [[Figure 2], inset], weak positivity for androgen receptor [Figure 2], focal positivity for Keratin, and melan-A expression.


   Discussion Top


Leydig cell tumors exhibit a bimodal peak of incidence in preadolescent and older (>50 years) age. About 3% are bilateral and 15% may extend beyond the testis at the time of presentation. This tumor has a capacity for estrogenic hypersecretion and gynecomastia is seen in 30% cases. [1] Inferior vena cava thrombosis has also been reported. [2] Adults may present with decreased libido. Leydig cell tumor has an incidence of 1-3% of all testicular neoplasms, [3] is usually benign and only about 1/10 th of them show malignant behavior in the form of metastatic disease, particularly to the lymph node, lung and liver. Malignant tumors occur exclusively in adults and are unaccompanied by endocrine changes. Features of malignancy include a larger size of tumor (6.9 cm vs. 2.7 cm in benign), infiltrative margins, foci of necrosis, angiolymphatic invasion, nuclear atypia, mitotic count >3/10 hpf, DNA aneuploidy, and increased MIB-1 activity. [1],[4],[5] The differential diagnosis considered was large cell calcifying Sertoli cell tumor (LCCSCT) which commonly has a retiform pattern. [6],[7] This tumor occurs in the second decade and has large cells with eosinophilic cytoplasm, foci of calcification and psammoma bodies and is known to have an intratubular component not so far described in Leydig cell tumors. [7]

Our patient was young and did not fit into either of the known age incidence peaks. Morphological features like a larger size (14 cm), foci of necrosis and calcification, moderate nuclear atypia, and infiltrative margins favored a diagnosis of malignancy. On the other hand, the mitotic activity was low (<1/10 hpf) and there was no angiolymphatic invasion or extension beyond the capsule of the testis. Six months after surgery the patient showed no evidence of metastasis. Orchiectomy is the accepted mode of treatment but follow-up is essential in such a case with a potential for malignant behavior.

Take Home Messages

  1. Leydig cell tumor is a rare testicular non-germ cell tumor, which is usually benign.
  2. Features of malignant behavior are age (~40 years), size (>7 cm), cytological features of atypia, mitosis (>3/10 hpf), infiltration beyond the capsule and distant metastasis.
  3. Cases which fall in the grey zone like ours need to be followed up carefully for metastasis.


 
   References Top

1.Tichoo SK, Tamboli P, Warner NE, Amin MB. Testicular and paratesticular tumors. In; Weidner N, Cote RJ, Suster S, Weiss LM, editors. Modern Surgical Pathology. Philadelphia: Saunders, Elsevier Science; 2003. p. 1215-56.  Back to cited text no. 1    
2.Moltó Marhuenda J, Mora Rufete A, Gonzαlvez Gasch A, Sαnchez Sevillano A, López Menιndez V, Martνn Hidalgo A. Leydig cell tumor, gynecomastia, and inferior vena cava thrombosis. An Med Interna 2001;18:432-4.   Back to cited text no. 2    
3.Cruceyra Betriu G, Tejido Sαnchez A, Duarte Ojeda JM, Garcνa De La Torre JP, De La Morena Gallego JM, Martνnez Silva V, et al . Leydig cell tumor: Report of 8 cases and review of the literature. Actas Urol Esp 2002;26:36-40.   Back to cited text no. 3    
4.Cheville JC, Sebo TJ, Lager DJ, Bostwick DG, Farrow GM. Leydig cell tumor of the testis: A clinicopathologic, DNA content and MIB-1 comparison of nonmetastasizing and metastasizing tumors. Am J Surg Pathol 1998;22:1361-7.   Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Singh V, Chaudhary H, Srivastava A. Leydig cell tumor of the testis - A case report. Indian J Urol 2004;20:166.   Back to cited text no. 5    Medknow Journal
6.Mardi K, Sharma J. Testicular retiform Sertoli cell tumor: A problem in histopathologic diagnosis. Indian J Pathol Microbiol 2008;51:70-1.   Back to cited text no. 6  [PUBMED]  Medknow Journal
7.Shin SL, Outwater EK. Benign Large Cell Calcifying Sertoli Cell Tumor of the Testis in a Prepubescent Patient. AJR Am J Roentgenology 2007;189:W65-6.  Back to cited text no. 7    

Top
Correspondence Address:
Usha Agrawal
Institute of Pathology, ICMR, Post Box 4909, Safdarjang Hospital Campus, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.55005

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    Figures

  [Figure 1], [Figure 2]

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