Location
Suwanee, GA
Start Date
6-5-2025 1:00 PM
End Date
6-5-2025 4:00 PM
Description
Introduction: Classified as a sex-cord stromal tumor, testicular Leydig cell tumors (LCTs) are rare, accounting for only 1-2% of all testicular neoplasms. They are most common in men aged 30 to 60 and can produce androgens or less commonly estrogen. For patients with an estrogen-producing LCT, symptoms can include gynecomastia, loss of libido, erectile dysfunction, and infertility.
Case Presentation: A 33-year-old white male presented to his primary care physician with concerns of an inguinal hernia and was referred to a general surgeon, who incidentally discovered a mass involving the right testicle. The timeline for the mass is inconclusive but was estimated to be from two to five years with no obvious change in size noted. At presentation, he had fatigue, gynecomastia, erectile dysfunction, and tenderness of the mass to palpation. Family history included a paternal cousin with testicular cancer with metastasis to the lungs, but follow-up for this relative has not been maintained. Initial blood work showed low testosterone at 102.31 ng/dL [123.06 - 813.36 ng/dL] and negative tumor markers for alpha-fetoprotein, human choriogonadotropin and lactate dehydrogenase.
Scrotal ultrasound revealed a hypervascular solid mass in the inferior pole of the right testicle measuring 1.9 x 1.8 x 1.5 cm with a small right hydrocele and mild thickening of the right epididymis. A computed tomography scan of the chest, abdomen, and pelvis confirmed an inferior right scrotal density measuring 2.0 cm, bilateral gynecomastia, and a small fat-containing right inguinal hernia. The patient underwent a right radical orchiectomy. The gross specimen measured 1.5 x 1.5 x 1.4 cm, had a yellow-orange appearance, and was well-circumscribed with no invasion into the tunica albuginea or tunica vaginalis. Immunostaining only tested positive for inhibin which along with histological morphology confirmed a Leydig cell tumor.
Though pre-orchiectomy estradiol level was never measured, it was concluded to be estrogen-producing due to low levels of testosterone prior to surgery. Two weeks after surgery, bloodwork found low testosterone at 129 ng/dL [264 - 916 ng/dL] and normal estradiol at 27.2 pg/mL [7.6 - 42.6 pg/mL]. Treatment with Clomid showed an initial rise of testosterone to 570.31 ng/dL [123.06 - 813.36 ng/dL]. However, due to the patient’s symptoms of increased fatigue following treatment, additional blood work found normal testosterone at 489 ng/dL [264-916 ng/dL], but elevated estradiol at 60.9 pg/mL [7.6 - 42.6 pg/mL]. Pregnyl and Exemestane were added to the patient’s therapy by an infertility specialist, reducing the estradiol to normal values. The goal of this treatment was to reverse the patient’s hypogonadism while preserving fertility.
Discussion: The U.S. Preventive Services Task Force does not recommend testicular screening currently, but this case illustrates the importance of encouraging testicular self-examinations as well as increasing public awareness of the signs and symptoms of testicular neoplasms. Although rare, LCTs have a great prognosis, making early diagnosis and treatment of utmost importance.
Embargo Period
5-28-2025
Included in
Benign, estrogen-producing testicular Leydig cell tumor: a case report of an incidental finding explaining a patient’s infertility
Suwanee, GA
Introduction: Classified as a sex-cord stromal tumor, testicular Leydig cell tumors (LCTs) are rare, accounting for only 1-2% of all testicular neoplasms. They are most common in men aged 30 to 60 and can produce androgens or less commonly estrogen. For patients with an estrogen-producing LCT, symptoms can include gynecomastia, loss of libido, erectile dysfunction, and infertility.
Case Presentation: A 33-year-old white male presented to his primary care physician with concerns of an inguinal hernia and was referred to a general surgeon, who incidentally discovered a mass involving the right testicle. The timeline for the mass is inconclusive but was estimated to be from two to five years with no obvious change in size noted. At presentation, he had fatigue, gynecomastia, erectile dysfunction, and tenderness of the mass to palpation. Family history included a paternal cousin with testicular cancer with metastasis to the lungs, but follow-up for this relative has not been maintained. Initial blood work showed low testosterone at 102.31 ng/dL [123.06 - 813.36 ng/dL] and negative tumor markers for alpha-fetoprotein, human choriogonadotropin and lactate dehydrogenase.
Scrotal ultrasound revealed a hypervascular solid mass in the inferior pole of the right testicle measuring 1.9 x 1.8 x 1.5 cm with a small right hydrocele and mild thickening of the right epididymis. A computed tomography scan of the chest, abdomen, and pelvis confirmed an inferior right scrotal density measuring 2.0 cm, bilateral gynecomastia, and a small fat-containing right inguinal hernia. The patient underwent a right radical orchiectomy. The gross specimen measured 1.5 x 1.5 x 1.4 cm, had a yellow-orange appearance, and was well-circumscribed with no invasion into the tunica albuginea or tunica vaginalis. Immunostaining only tested positive for inhibin which along with histological morphology confirmed a Leydig cell tumor.
Though pre-orchiectomy estradiol level was never measured, it was concluded to be estrogen-producing due to low levels of testosterone prior to surgery. Two weeks after surgery, bloodwork found low testosterone at 129 ng/dL [264 - 916 ng/dL] and normal estradiol at 27.2 pg/mL [7.6 - 42.6 pg/mL]. Treatment with Clomid showed an initial rise of testosterone to 570.31 ng/dL [123.06 - 813.36 ng/dL]. However, due to the patient’s symptoms of increased fatigue following treatment, additional blood work found normal testosterone at 489 ng/dL [264-916 ng/dL], but elevated estradiol at 60.9 pg/mL [7.6 - 42.6 pg/mL]. Pregnyl and Exemestane were added to the patient’s therapy by an infertility specialist, reducing the estradiol to normal values. The goal of this treatment was to reverse the patient’s hypogonadism while preserving fertility.
Discussion: The U.S. Preventive Services Task Force does not recommend testicular screening currently, but this case illustrates the importance of encouraging testicular self-examinations as well as increasing public awareness of the signs and symptoms of testicular neoplasms. Although rare, LCTs have a great prognosis, making early diagnosis and treatment of utmost importance.
Comments
Awarded "Best Clinical Case Study" at PCOM Georgia Research Day 2025