Malignant Leydig Cell Adenoma of the Testicle

David I Rose, MD
Faye C Laing, MD

April 24, 1997

Presentation

An 89-year-old man presented with a palpable testicular mass.

Imaging Findings

US images of left testicle

Comparison US image of right testicle

Ultrasonic (US) images of the left testicle demonstrate a 4.8 cm heterogeneous intratesticular mass (black arrow) with echolucent septa (white arrows). The mass is hypoechoic compared to the surrounding normal testicular parenchyma. A small left hydrocele (arrow) is associated with this mass. A comparison image shows that the right testicle is normal.

Differential Diagnosis

The most common intratesticular mass in a man over the age of 60 is lymphoma. This disease usually presents as a diffuse lesion in the testicle, but it can be focal. Testicular metastases are the next most frequently encountered masses in men of this age group. Testicular metastases are most commonly seen with prostate or lung carcinoma but may be encountered with malignant melanoma and renal and gastrointestinal carcinomas. Metastases are commonly multiple and often bilateral. Less common lesions in a man of this age are germ cell tumors (seminoma, embryonal cell carcinoma, teratoma, choriocarcinoma, and yolk sac tumor) and stromal cell tumors (Leydig cell tumor and Sertoli cell tumor). Infection and vascular abnormalities are very unlikely given the sonographic appearance in this patient.

Diagnosis

Malignant Leydig cell tumor (confirmed by pathology)

Discussion

Scrotal ultrasound can detect intrascrotal masses with a sensitivity of nearly 100%. It plays a major role in the evaluation of scrotal masses because of its accuracy of 98%-100% in differentiating intratesticular and extratesticular pathology. This distinction is important because the majority of extratesticular masses are benign, while most intratesticular masses are malignant. An intratesticular mass should be considered malignant until proven otherwise.

While ultrasound is excellent for detecting testicular lesions, it is not as successful in differentiating between types of lesions. Most malignant testicular neoplasms are hypoechoic when compared to the surrounding normal parenchyma, but hemorrhage, calcification, necrosis, or fatty changes can increase echogenicity within these lesions. Uniformly echogenic masses are quite often benign in etiology, such as infection or vascular abnormalities, but both benign and malignant processes can be nonspecific in appearance. Biopsy is therefore crucial for diagnosis.

Leydig (interstitial) cell tumors are uncommon, accounting for 1-3% of all testicular neoplasms, and occur predominantly in men between the ages of 20 and 50 years. Patients most commonly present with painless testicular enlargement or a palpable mass. Gynecomastia resulting from the secretion of androgens, estrogens or both occurs in approximately 15% of patients and may be the presenting symptom. Impotence, loss of libido, and precocious virilization may occur in young men. The tumor is bilateral in 3% of patients. Only 10-15% of Leydig cell tumors are malignant, as in this case. They are usually small, solid and hypoechoic on ultrasound. Foci of hemorrhage and necrosis are present in 25% of tumors and may enlarge the tumor by forming cystic spaces.

References

1. Stewart R and Carroll BA. The scrotum. In: Rumack CM, Wilson SR, Charboneau JW, editors. Diagnostic ultrasound. St Louis: Mosby, 1991:570-575.

2. Male genital system. In: Cotran RS, Sumar V, Robbins SL, editors. Robbins pathologic basis of disease. Philadelphia: Saunders, 1989:1115.

Return to the Teaching Case Database search page
Return to Professional Education
About BrighamRAD

Dear Visitors: Nothing on this World Wide Web site should be considered medical advice. Only your own doctor can help you make decisions about your medical care. It is not the policy of the Brigham and Women's Hospital Department of Radiology to provide consultation on the World Wide Web or via e-mail. If you have a specific medical question or are seeking medical care, please call the Brigham and Women's Hospital toll-free physician referral line at 1-800-294-9999.

Is this a mirrored page?
The official homepage of the BrighamRAD Teaching Case Database is http://brighamrad.harvard.edu/education/online/tcd/tcd.html

Contact the BrighamRAD Design Team for additional information about this website.