Nonpalpable Leydig's Cell Tumors Diagnosed by Fine Needle Aspiration

Abstract

Leydig's cell tumor of the testicle is rare, constituting 1 to 2% of all testicular tumors. They are commonly detected as palpable masses but can present with precocious puberty, gynecomastia or infertility. The tumor is usually diagnosed by and definitively treated with orchiectomy. We present a case of nonpalpable, bilateral Leydig's cell tumor presenting as infertility, diagnosed by fine needle aspiration and managed conservatively with serial imaging to allow for paternity. CASE REPORT A 29-year-old man presented with a 1.5-year history of primary infertility. Physical examination was difficult due to a small, thick scrotum but revealed asymmetric fullness in the left spermatic cord and left testicular atrophy. Several semen analyses demonstrated severe oligo-asthenospermia (less than 1 x 106 motile sperm). Scrotal ultrasound revealed no varicocele. However, a 5 X 5 X 6 mm., intraparenchymal hypoechoic lesion was noted in the right testicle. Serum luteinizing hormone, follicle-stimulating hormone, a-fetoprotein, lactate dehydrogenase, p-human chorionic gonadotropin and total testosterone were normal. T2-weighted magnetic resonance imaging revealed that the lesion had low signal intensity consistent with scar tissue. The mass was managed with close observation and serial ultrasound, and the infertility was treated with empiric clomiphene citrate. The patient was advised to bank sperm. Scrotal ultrasound, serum a-fetoprotein and &human chorionic gonadotropin 2 months later were unchanged. Ultrasound at 4 months revealed that the right testicular lesion had increased in size to 9 x 9 X 8 mm. (fig. 1). In addition, a new, ill-defined, 8 x 8 x 7 mm., slightly hypoechoic lesion was noted in the left testicle. Given the improbability that the lesion was fibrotic, a tissue diagnosis was recommended. Fine needle aspiration of both testis lesions was performed with local anesthesia and ultrasound guidance. Through a 23