STEPTRACKERREPRODUCTIVE + ONCOLOGY | PATHOLOGY + ENDOCRINE | HIGH-YIELD REVIEW

Testicular Sex Cord–Stromal Tumors, Lymphoma & Other Masses

Testicular tumors that make hormones, the cancer of older men's testes, and the masses that depend on the patient's age.

FOCUS ON
Leydig cell tumor: golden-brown, Reinke crystals, androgens or estrogens → precocious puberty in boys, gynecomastia in men; usually benign. Sertoli: usually silent, benign. Testicular lymphoma (DLBCL) = most common testicular cancer in men > 60, often bilateral. Boys: yolk sac, teratoma, leukemia (sanctuary site). CAH: bilateral adrenal rest tumors.
TUMOR · MASS
ORIGIN · MECHANISM
FEATURES
CLUE
Leydig cell tumor
most common sex cord–stromal
Interstitial cells; make androgens (± aromatized to estrogen)
Golden-brown mass; polygonal cells with Reinke crystals
Boys: precocious puberty · men: gynecomastia, ↓ libido · usually benign
Sertoli cell tumor
Sustentacular cells forming tubules
Usually hormonally silent; may make estrogen
Large cell calcifying type: Peutz-Jeghers, Carney complex
Granulosa cell tumor (testis)
Rare; juvenile form in infants
May cause gynecomastia
Call-Exner bodies
Testicular lymphoma
most common in men > 60
Usually diffuse large B-cell lymphoma, primary or secondary
Painless enlargement, often bilateral; aggressive
Spreads to CNS and opposite testis
Leukemic infiltration
Blood-testis barrier shields cells from chemo
Painless enlargement in a boy with ALL
Testis is a sanctuary site for relapse
Testicular adrenal rest tumors
Adrenal-like tissue in the testis stimulated by high ACTH
Bilateral masses in men with congenital adrenal hyperplasia
Shrink with glucocorticoid replacement
Spermatocytic tumor
Germ cell tumor not from GCNIS
Men > 65
Excellent prognosis
Adenomatoid tumor
Benign mesothelial tumor of the epididymis
Small firm paratesticular nodule
Most common paratesticular tumor
Paratesticular rhabdomyosarcoma
Embryonal rhabdomyosarcoma of spermatic cord
Children and teens; scrotal mass separate from testis
Desmin, myogenin ⁺
Metastases to the testis
Hematogenous spread
Older men: prostate, lung, kidney, melanoma
Often bilateral

Mechanism — hormone effects of Leydig tumors

Leydig tumor
→
↑ Testosterone
→
BoyPrecocious puberty, ↑ height, voice change
AromataseTestosterone → estradiol
→
ManGynecomastia, ↓ libido
→
↓ LH/FSHFeedback
→
Opposite testis atrophies

Testicular mass by age

AGE
MOST LIKELY
CLUE
Infant / toddler
Yolk sac tumor, teratoma (benign)
↑ AFP
Child with ALL
Leukemic infiltration
Relapse site
Child / teen (cord)
Rhabdomyosarcoma
Separate from testis
15–35
Germ cell tumor
Markers, i(12p)
Any age, hormonal
Leydig cell tumor
Reinke crystals
> 60
Lymphoma, spermatocytic tumor, mets
Bilateral

How it's tested

COMMON CONFUSIONGynecomastia with a testicular mass can come from a Leydig cell tumor (estrogen) or a choriocarcinoma (hCG). Check hCG: high → germ cell; normal with high estradiol → Leydig.
THE TRAPA testicular mass in a 70-year-old is not a seminoma until proven otherwise — it is most likely lymphoma.
YOUR APPROACHAge → bilateral or not → hormone effects (puberty, gynecomastia) → markers (AFP, hCG, estradiol) → histology clue (Reinke crystals, lymphoid sheets).

If you see… think…

6-year-old boy with pubic hair, deep voice and a testicular mass → Leydig cell tumor
Rod-shaped eosinophilic crystals in tumor cells → Reinke crystals (Leydig)
Man with gynecomastia, testicular mass, normal hCG, ↑ estradiol → Leydig cell tumor
Peutz-Jeghers boy with calcifying testicular tumor → large cell calcifying Sertoli tumor
72-year-old with bilateral testicular enlargement → testicular lymphoma (DLBCL)
Boy in ALL remission with a swollen testis → leukemic relapse (sanctuary)
Man with CAH and bilateral testicular masses → adrenal rest tumors
Small benign nodule of the epididymis → adenomatoid tumor
Teen with mass in the spermatic cord, desmin⁺ → rhabdomyosarcoma
Older man with prostate cancer and testicular nodule → metastasis