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Case of the Month

September 2008

Patient Data: 19 year old male

Clinical Info: Palpable mass behind both nipples and a mass in the right testis

Hypoechoic lesion behind the right nipple

Hypoechoic lesion behind the left nipple

Longitudinal image of the enlarged right testis with an inhomogeneous mass

Longitudinal image of the enlarged right testis with cystic areas in the testicular mass

Longitudinal image with e-flow of the enlarged right testis with irregular vascularity in the testicular mass

Longitudinal image with e-flow of the normal left testis

The hypoechoic structure behind the nipple is caused by a bilateral gynaecomastia. The testicular mass proved to be an embryonal cell carcinoma.

Gynecomastia in children or young adults may be the result of a variety of conditions, most of these conditions are innocent. However gynaecomastia may be the result of hormonal activity of a testis tumor.

Some testis tumors secrete estrogen which, in turn, can cause gynecomastia.

Gynecomastia may also occur in patients with testis tumors that produce human chorionic gonadotropin (HCG).

Examples of estrogen-secreting tumors include: Leydig cell tumors, Sertoli cell tumors and granulosa cell tumors.

Interstitial cell tumors, or Leydig cell tumors constitute 1%-3% of all testis tumors. Usually, they occur in men between the ages of 20 and 60, although up to 25% of them occur prepubertally. Though mostly benign, Leydig cell tumors may be malignant and metastasize.

Sertoli cell tumors comprise less than 1% of all testicular tumors and occur at all ages, but one third have occurred in patients less than 13 years, usually in boys under 6 months of age. Although they arise in young boys, they usually do not produce endocrine effects in children. The majority are benign, but up to 10% are malignant. Gynecomastia occurs in one third of cases of Sertoli cell tumors.

Granulosa cell tumors, occurring very rarely in the testes, can also overproduce estrogen.

Germ cell tumors are the most common cancer in males between the ages of 15 and 35. They are divided into seminomatous and nonseminomatous subtypes and include embryonal carcinoma, yolk sac carcinoma, choriocarcinoma and teratomas. As a result of the increased beta HCG acting analogously to LH to stimulate the Leydig cell LH receptor, testicular estrogen production is also increased.

It is important to realize that gynaecomastia in most patients is not caused by endocrine activity of a testis tumor. In a small percentage the gynaecomastia is the result of endocrine activity of a testis tumor. This can be a malignant nonseminomatous tumor as in this case or an interstitial tumor of which some can also be benign.

For more examples of testis tumors and gynaecomastia see:

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 Jan-Feb;22(1):189-216. Review.
Daniels I, Layer G. Testicular tumours presenting as gynaecomastia . European Journal of Surgical Oncology , Volume 29 , Issue 5 , Pages 437 - 439

Copyright © Dr. T.S.A. Geertsma, Ziekenhuis Gelderse Vallei, Ede, The Netherlands. All rights reserved.

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