A 32-year-old Caucasian man was diagnosed with a left 1.2 cm solid testicular mass during evaluation of new gynecomastia (see image). He underwent a computed tomography scan of the chest, abdomen, and pelvis that did not demonstrate evidence of retroperitoneal lymphadenopathy and his tumor markers (AFP, B-HCG, LDH) were within normal limits.
Submit your diagnosis to see full explanation.
This clinical quiz was prepared by Marc C. Smaldone, MD, MSHP, FACS, of Fox Chase Cancer Center
1. Olivier P, Simoneau-Roy J, Francoeur D, et al. Leydig cell tumors in children: contrasting clinical, hormonal, anatomical, and molecular characteristics in boys and girls. J Pediatr. 2012;161:1147-52. doi: 10.1016/j.jpeds.2012.05.039.
2. Laclergerie F, Mouillet G, Frontczak A, et al. Testicle-sparing surgery versus radical orchiectomy in the management of Leydig cell tumors: results from a multicenter study. World J Urol. 2018;36:427-433.
Although there is no single histologic criteria to define malignant Leydig cell tumors, malignant tumors are usually larger (>5cm), and show nuclear atypia, increased mitotic figures, infiltrative margin, angiolymphatic invasion, necrosis, or DNA aneuploidy.
After extensive counseling, the patient elected to proceed with a left radical inguinal orchiectomy for definitive management. Pathology revealed a well circumscribed 1.2 cm Leydig cell tumor with extremely rare mitoses and no vascular invasion.
Leydig cell tumors are a member of the sex-cord stromal tumor group of ovarian and testicular cancers that arise most in young adults. Patients often present with precocious puberty in pre-pubertal boys, but can cause feminization in adults such as gynecomastia, erectile dysfunction, infertility, feminine hair distribution, and loss of libido.1 While the vast majority are benign, 10% are malignant and can metastasize to lymph nodes (retroperitoneal and inguinal), liver, lung, and bone. The gold treatment standard treatment is radical orchiectomy, but partial orchiectomy is also an option.2 For patients with malignant histology, the role of systemic chemotherapy is unclear, but retroperitoneal lymph node dissection is also recommended.