Gynecomastia Secondary of Leydig Cell Tumor: Case Report

Abstract

INTRODUCTION: The prevalence of gynecomastia ranges between 32 and 65% of men in some time of their lives. It comes from imbalance of estrogen and testosterone and the most common cause is physiologic: 75%. Testicular malignances are account for 3% of causes of gynecomastia, presenting so evident gynecomastia, testicular asymmetry or hyperestrogenism. Leydig cell tumor represents 1 to 3% of testicular cancers in any age. It is more frequent between 25 and 35 years- old. Its remarkable clinical presentation is palpable testicular nodule (80 to 90%) associated to endocrine changes which can express as early virilization, infertility, sexual impotence or gynecomastia. We described a case of this tumor of which first finding was gynecomastia. CASE REPORT: A 34 years-old man has perceived painful breast enlargement since October 2009. The physical findings were bilateral gynecomastia and palpable mass in left testis. In 2010, mammogram has showed right lateral upper quadrant lump, categorized as BI-RADS 0 and ultrasound revealed bilateral gynecomastia. He had elevated estrogen and diminished testosterone. Human chorionic gonadotrophin, a-foeto protein and lactic desidrogenase were normal. In July 2011, testicular ultrasound revealed hipoecogenic nodule in distal one third left testis, measuring 1.5 cm, with hypervascularization on Doppler scan and enlargement of tunica albuginea. In August 2011, left radical orchiectomy was performed and the histopathological exam was unifocal Leydig cell tumor measuring 1. 4 cm, spermatic cord free of neoplasia and negative resection margins. The immunohistochemical stain was positive to vimentin and inhibin. His stage was I. DISCUSSION: We described a rare case of gynecomastia secondary to Leydig cell tumor and as first clinical manifestation. The gynecomastia results from increment of estrogens produced directly by tumor or provided by aromatization of other hormones synthesized by malignancy. Its frequency is bigger among young adults and it can precede months or years usual clinical findings of the tumor, considering its presence as good prognostic evidence. The testicular ultrasound has confirmed the diagnosis and has fundamental role mainly when the tumor is not still palpable. The standard therapy is radical orquiectomy. After that, commonly the gynecomastia regresses spontaneously in 80% of cases; in the same way, estrogen and testosterone become normal. Others 20% need surgical treatment of gynecomastia. This should not be achieved less one year after orchiectomy: its evolution can indicate cure or recidive of testicular tumor.