British Journal of Radiology (2004) 77, 521-524
© 2004 British Institute of Radiology
doi: 10.1259/bjr/31653779
MRI in the diagnosis of testicular Leydig cell tumour
G C Fernández, MD1,
F Tardáguila, MD1,
C Rivas, MD1,
C Trinidad, MD1,
D Pesqueira, MD2,
E Zungri, MD2 and
P San Miguel, MD3
Departments of 1 Radiology, 2 Urology and 3 Pathology, Povisa Medical Centre, Salamanca St. 5, 36211 Vigo (Pontevedra), Spain
 |
Abstract
|
|---|
We report the appearance of three cases of Leydig cell tumours on MRI. This imaging method showed well-defined and peripheral intratesticular tumours displaying marked and homogeneous enhancement when contrast medium was used. This latter finding was only observed in Leydig cell tumours when they were compared in a series of 104 patients with different scrotal pathologies.
|
Introduction
|
|---|
Sex cord-stromal tumours represent about 4% of testicular neoplasms. Leydig cell tumours (LCTs) accounting for nearly 3% are the most frequent. They have two age peaks of incidence, with about 20% of cases occurring in children, commonly between 5 years and 10 years, being very infrequent under 2 years. The second age peak is in adults, usually between 20 years and 60 years. In children, these tumours are presumably smaller at the time of detection due to their androgen production causing the clinical features of isosexual pseudoprecocity in practically all patients. In adults, androgen production is much less readily detected than in children, presenting a testicular mass or developing gynaecomastia in about 30% of patients [1]. Bilateral cases have been reported in 3% [2, 3]. LCTs have been associated with cryptorchidism, testicular atrophy and infertility. Familial occurrence is also described [1]. Although LCTs are usually clinically benign, about 10% of reported cases have been associated with a malignant course. Metastatic disease is the only reliable criterion of malignancy since the diagnosis cannot be made on the basis of pathological features [1–4].
Ultrasound is considered the initial investigative method for the diagnosis of LCT in the testis, showing a well-defined intratesticular mass in a patient with gynaecomastia [5–9]. However, it is not usually possible to make a specific diagnosis with ultrasound [10]. Recently, MRI has become more widely used as an imaging modality in scrotal disease, especially when a contrast medium is used [11–13]. In this regard, we report three cases of LCTs studied by MRI and describe their most characteristic findings.
|
Case 1
|
|---|
A 44-year-old man was referred for further evaluation of gynaecomastia and high levels of oestradiol in blood and 17 ketosteroids in urinary excretion. He had no clinical symptoms. Ultrasound (7.5 MHz PowerVision; Toshiba, Tokyo, Japan) revealed a 2 cm round mass in the right testicle with well-defined borders and peripheral location within the testicular parenchyma. MRI was performed with a 0.5 T unit (Gyroscan T5; Philips Medical Systems, The Netherlands) using T1 weighted spin-echo images before and after contrast (repetition time (TR)/echo time (TE): 572/20, field of view (FOV): 180 mm, thickness: 6 mm, interslice gap 0.6 mm and matrix: 256), and T2 weighted fast spin-echo images (TR/TE: 3257/120, FOV: 180 mm, thickness: 6 mm, interslice gap: 0.6 mm and matrix: 256). On T1 weighted pre-contrast images, the tumour could not be observed because it had a similar signal to the rest of the testicular parenchyma. However, after administration of Gd-DTPA (0.1 mmol kg–1 Omniscan®; Nycomed Ireland, Ltd), the lesion showed marked and homogeneous enhancement that permitted observation of the morphology, size and location of the tumour (Figure 1a, b
). On T2 weighted images, the tumour exhibited low signal intensity and it was partially surrounded by a line of high signal intensity (Figure 1c).
View larger version (104K):
[in this window]
[in a new window]
|
Figure 1. Case 1. (a) Non-enhanced and (b) contrast enhanced T1 weighted sequence demonstrate a very marked tumour enhancement with peripheral location in testicular parenchyma. (c) On T2 weighted image the tumour is hypointense with central areas of high signal due to scars. (d) Gross pathology shows a 2 cm yellow lobulated tumour. Central scars are seen.
|
|
Staging studies did not reveal metastases and the patient underwent partial orchidectomy. Pathological results confirmed a LCT (Figure 1d
).
|
Case 2
|
|---|
A 42-year-old man was admitted with a palpable testicular lesion in the right testis. No other signs or symptoms were found in the clinical history. Laboratory results, including tumoral markers, were normal. Ultrasound findings confirmed a cyst in the head of the right epydidymis. However, ultrasound exploration of the contralateral testicle (left testis) showed an incidental solid intratesticular tumour. MRI was performed showing a lesion with marked enhancement on post-contrast images (Figure 2a, b). On T2 weighted images, the tumour showed low signal intensity surrounded by a thin border of high signal intensity (Figure 2c). These MRI findings prompted us to diagnose a LCT and urologists were informed of this possibility. The patient underwent a partial orchidectomy and pathological findings confirmed a LCT.
View larger version (75K):
[in this window]
[in a new window]
|
Figure 2. Case 2. (a) Non-enhanced and (b) contrast enhanced T1 weighted sequence show a marked enhancement of the lesion. (c) On T2 weighted image the tumour has a bright rim surrounding the lesion.
|
|
|
Case 3
|
|---|
A 31-year-old man who presented with right gynaecomastia was referred for an ultrasound examination. He had never had pain or swelling on the scrotum and physical exploration was irrelevant. Laboratory results including tumoral markers were normal. Testicular ultrasound demonstrated a 3 cm intratesticular tumour in the right testis with well-defined margins and hypoechogenic areas in the centre of the tumour. On pre-contrast images, the tumour was isointense in relation to testicular parenchyma making it very difficult to localize. Post-contrast images revealed marked enhancement of the tumour with less enhanced central areas (Figure 3a, b). T2 weighted MR images displayed a lobulated and defined intratesticular lesion with central areas of high signal intensity (Figure 3c). In this regard a pre-operative diagnosis of LCT was made. Staging CT did not reveal metastases and partial orchidectomy was performed preserving the rest of testicular parenchyma. Pathological results confirmed the diagnosis of LCT.
View larger version (74K):
[in this window]
[in a new window]
|
Figure 3. Case 3. (a) Non-enhanced and (b) contrast enhanced T1 weighted sequence show a similar findings with a strong enhancement of the tumour. (c) On T2 weighted image the tumour is readily observed showing a large central scar with high signal intensity.
|
|
|
Discussion
|
|---|
Ultrasound is the imaging method for of choice the diagnosis of LCT, when a patient has gynaecomastia [5–9]. The tumours appear as small lesions with well-defined borders in a peripheral location within the testicular parenchyma. The diagnosis of LCT should be considered when patients present gynaecomastia and the above ultrasound appearance.
Until recently, MRI findings have not been commonly reported in the literature, because this imaging method is not usually performed in the study of scrotal diseases, although there are now more frequent reports, particularly reporting on contrast-enhanced appearance [11, 12]. In our cases, MRI showed marked enhancement on post-contrast images that could be considered a reliable sign in the detection of LCT and enabling differentiation from other testicular tumours. In this setting, we have compared MRI findings in 104 patients with different testicular pathologies and no other lesion showed a similar appearance on enhanced MRI. This strong enhancement of the LCT can probably be explained by the vascularity of the tumour and/or its stromal tissue (myxoide and fibrous in almost all LCTs) explaining both the marked and maintained enhancement of the tumour [4].
LCTs are easily detected on T2 weighted images displaying low signal intensity in relation to testicular parenchyma. In one case, pathological features showed a well-defined circumscribed tumour, separate from the adjacent testis by a fibrous capsule rim. This may be the reason why, in the second patient, the margin surrounding the tumour had a high signal on T2 weighted images. Also, it is interesting to highlight the presence of high signal intensity areas within the tumours, which correlated pathologically with central scars.
Although, this is a small series of three cases, we believe that MRI can help establish an accurate pre-operative LCT diagnosis. In this regard, urologists have to be aware of this possibility because they may consider a partial orchidectomy if staging does not reveal metastases since only a few LCTs become malignant. Several authors emphasise conservative surgery in patients with only one testis, those who wish to remain fertile or those who refuse androgen supplementation [14, 15].
In conclusion, the MRI findings of LCT are marked enhancement on post-contrast T1 weighted images, low signal intensity signal on T2 weighted images with high signal intensity foci secondary to central scars and a capsule with high signal intensity on T2 weighted images may be observed in some cases.
Received for publication December 4, 2002.
Revision received June 26, 2003.
Accepted for publication September 24, 2003.
|
References
|
|---|
- Kim I, Young RH, Scully RE. Leydig cell tumors of the testis. A clinicopathological analysis of 40 cases and review of the literature. Am J Surg Path 1985;9:177–92.[Medline]
- Corrie D, Norbeck JC, Thompson IM, et al. Ultrasound detection of bilateral Leydig cell tumors in palpable normal testes. J Urol 1987;137:747–8.[Medline]
- Pereira JG, Ateca R, Ullate V, Gutierrez JM, Ramirez MM, Etxezarraga MC, et al. Metachroneous contralateral Leydig cell tumor of the testis. Actas Urol Esp 2001;25:133–8.[Medline]
- Ponce de Leon J, Algaba F, Bassas L, Villavicencio H. Leydig cell tumor of the testis. Arch Esp Urol 2000;53:453–8.[Medline]
- Anderson MS, Brogi E, Biller BM. Occult Leydig cell tumor in a patient with gynecomastia. Endocr Pract 2001;7:267–71.[Medline]
- Grantham JG, Charboneau JW, James EM, et al. Testicular neoplasms: 29 tumors studied by high-resolution US. Radiology 1985;157:775–80.[Abstract/Free Full Text]
- Conway GS, MacConnell T, Wells G, Slater SD. Importance of scrotal ultrasonography in gynaecomastia. BMJ 1988;297:1176–7.
- Stoll S, Goldfinger M, Rothberg R, Buckspan MB, Fernandes BJ, Bain J. Incidental detection of impalpable testicular neoplasm by sonography. AJR 1986;149:349–50.
- Emory TH, Charboneau JW, Randall RV, Scheithauer BW, Grantham JG. Occult testicular interstitial-cell tumor in a patient with gynecomastia: ultrasound detection. Radiology 1984;151:474.[Abstract/Free Full Text]
- Woodward PJ, Sohaey R, O'Donoghue MJ, Green DE. From the Archives of the AFIP: Tumors and tumorlike lesions of the testis: radiologic-pathologic correlation. RadioGraphics 2002;22:189–216.[Abstract/Free Full Text]
- Watanabe Y, Dohke M, Ohkubo K, et al. Scrotal disorders: evaluation of testicular enhancement patterns at dynamic contrast-enhanced subtraction MR imaging. Radiology 2000;217:219–27.[Abstract/Free Full Text]
- Tamayo JC, Rodríguez F, Hontoria JM, Sánchez M, Martínez V, Viaño J. The Leydig-cell testicular tumor. A case report with magnetic resonance images. Arch Esp Urol 1988;51:928–31.
- Cramer BM, Schlegel EA, Thueroff JW. MR imaging in the differential diagnosis of scrotal and testicular disease. Radiographics 1991;11:9–21.[Abstract]
- Ciftci AO, Bingol-Kologlu M, Senocak ME, Tanyel FC, Buyukpamukcy M, Buyukpamukcy N. Testicular tumors in children. J Pediatr Surg 2001;36:1796–801.[CrossRef][Medline]
- Masoudi JF, Van Arsdalen K, Rovner ES. Organ-sparing surgery for bilateral Leydig cell tumor of the testis. Urology 1999;54:744.
Top
Abstract
Introduction
