Case 4 -

Intratubular Large Cell Hyalinizing and Calcifying Sertoli Cell Neoplasia of the Testis in a child with Peutz-Jeghers Syndrome Liliane Boccon-Gibod Hopital Armand-Trousseau Assistance Publique-Hopitaux de Paris Paris, France

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Case History A boy born in March 1999 presented at age 4 with learning difficulties, attention deficit disorder and was treated for 2 years by Ritaline. At age 5, resection of a nasal polyp was performed. At age 7, a unilateral localized left gynecomastia associated with acceleration of growth velocity led to endocrine evaluation and testicular ultrasonography. Both testes were moderately and equally hypertrophied. At ultrasonography, multiple, bilateral dot-like calcifications were present in the 2 testes, associated with a nodule of larger confluent calcifications (7x5mm) in the right testis (the slides submitted are from the right testicular nodule). Small bilateral cysts into the epididymis were also noted. Endocrine evaluation showed: low testosterone (< 0, 10 ng/ml), high estradiol (32,4 pg/ml) and markedly elevated inhibin-α (156 pg/ml). Immediately after ablation of the testicular nodule, estradiol levels began to lower and testosterone to rise but testosterone levels lowered again soon. On account of the low risk of malignant transformation of the intra tubular LCH Sertoli cell neoplasia, a conservative treatment was decided. Medical treatment was warranted to reduce the effects of elevated estrogens on the breast and bone maturation. Aromatase inhibitors are the best option, according to the recent literature. Anastrazole (3rd generation inhibitor of estrogen synthesis) was given 4 months after surgery. Within the next 4 months, estradiol reached normal range and gynecomastia disappeared. Growth velocity and skeletal maturation have decreased under this treatment. Case 4 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 4 - Figure 1 At low power, cluster of expanded seminiferous tubules with thickened peritubular basement membrane. The stroma is denser than that associated with normal tubules at bottom right Case 4 - Figure 2 Intratubular proliferation of large Sertoli cells, with eosinophilic or clear cytoplasm, replacing all germ cells and filling the lumen. Case 4 - Figure 3 On the right, two seminiferous tubules that are filled by large Sertoli cells, with eosinophilic or vacuolated cytoplasm and euchromatic, ovoid nuclei. Their thickened basement membrane extends and invaginates into the lumen. Case 4 - Figure 4 Among normal seminiferous tubules, one tubule with a PAS-positive, thickened and invaginated basement membrane Case 4 - Figure 5 A small cluster of expanded seminiferous tubules with intratubular Sertoli cell proliferation and globular eosinophilic basement membrane deposits, partially calcified in the larger tubule. Case 4 - Figure 6 A group of expanded tubules with numerous intraluminal psammomatous calcifications replacing the large proliferated Sertoli cells. Case 4 - Figure 7 (Inhibin) Strong inhibin reactivity of the intratubular large proliferated Sertoli cells. In normal seminiferous tubules, weaker reactivity of normal Sertoli cells. Follow up At the time the testicular nodule was resected (May 2006) the diagnosis of Peutz-Jeghers Syndrome was highly suspected in the presence of perioral pigmentation, and calcifying testicular lesion with gynecomastia but the search for mutation for the STK11/LKB1 gene was only under scrutiny. Blood samples had been sent for molecular testing. Standard techniques checking for STK1 gene mutations covering 70% of mutations present in Peutz-Jeghers Syndrome (exons 2 and 5-8) were initially negative (October 2006). A few months later, results from White Blood Cells examination in another institution were positive for molecular diagnosis of McCune-Albright Syndrome (somatic mutation of arginin 201 with positivity from protein G as). Therefore for a few months, and despite clinical manifestations more in favor of Peutz-Jeghers Syndrome, McCune-Albright Syndrome was the considered diagnosis until in September 2007 a different technique for the study of STK1 mutation was performed (MLPA = Multiple Ligation-dependent Probe Assay) and found a deletion limited to promotor and exon 1 of gene STK11. This deletion had been described previously with Peutz-Jeghers Syndrome in the literature and Peutz-Jeghers Syndrome diagnosis was therefore ascertained. Pathologic Features The resected nodule measured 1cm diameter. Among normal prepubertal testicular tubules, there were patchy distributed expanded tubules, solitary or in clusters. These tubules were filled with enlarged Sertoli cells and surrounded by a thickened peritubular basement membrane which could be invaginated into the tubules. Sertoli cells had a large pale or eosinophilic cytoplasm with ovoid, uniform nuclei. Mitosis were scarce. These tubules did not contain germ cells. There was no definite neoplastic Sertoli cell cords as seen in Sertoli cell tumors. The basement membrane appeared multilayered and intensely PAS positive, invaginating into hyalinized, PAS positive cores. Numerous foci of dystrophic calcifications were present within many of the enlarged tubules, apparently developed from this thickened, invaginated basement membrane. Immunohistochemical stains were performed with appropriate reactive controls. Inhibin-α was strongly positive in large proliferated Sertoli cells. Discussion Peutz-Jeghers Syndrome Peutz-Jeghers Syndrome is a rare autosomal dominant disorder characterized by the association of benign gastrointestinal hamartomatous polyps, mucocutaneous pigmentation and increased risk of developing various neoplasms, including gonadal sex cord tumors. In the present case, GI tract polyps were not present (ileocoloscopy and oesogastroduodenoscopy were normal). Nasal polyps and Peutz-Jeghers Syndrome One nasal polyp had been removed in our case, in 2004, 2 years prior to the apparition of gynecomastia. In the title of Dr Peutz's initial report in 1921, nasal polyps were mentioned as part of the entity, but had seldom been described in the following decades. In a recent publication, nasal polyps have been reported in 16% of Dutch patients with Peutz-Jeghers Syndrome. According to this study, nasal polyps in Peutz-Jeghers Syndrome present with less eosinophilia than sporadic nasal polyps. Within polyp tissue, LOH at 19p. 13.3 indicating inactivation of the wild type STK11/LKB1tumor suppressor gene has been found in 50% of PJ patients but not in 28 sporadic nasal polyps studied as control. Therefore nasal polyps must not be forgotten as a possible clinical manifestation of Peutz-Jeghers Syndrome. Sertoli Cell proliferations of the testis and Peutz-Jeghers Syndrome Mutations of the STK11 tumor suppressor gene located on the short arm of chromosome 19 predispose patients with Peutz-Jeghers Syndrome to different type of neoplasms. In boys, testicular lesions involving Sertoli cells have been increasingly recognized as a cause of prepubertal gynecomastia and other estrogenic manifestations. This process has been described in sporadic cases or short series as Sertoli Cell Tumors (including Large Cell Calcifying Sertoli Cell Tumor), Intra Tubular Sertoli Cell Tumors(or neoplasias, or proliferations), sex cord tumor with annular tubules, "aromatase producing sex cord tumor". The variety of terminology reflects the doubt to whether these entities are true neoplasms and what are their prognostic significance. Their presumed neoplastic nature has led in the past to recommend bilateral orchidectomy (Young S 1995, Am J Surg Pathol). The true nature of this lesion is therefore of great importance due to the potential consequence of the choosen treatment. A recent publication by Ulbright et al with review of 26 cases including 8 from their own files allows a more clear view of the true nature and potential of these Sertoli Cell proliferations. The distinctive clinical background presented a unique clinico-pathological profile : gynecomastia and advanced bone age, both linked to increased serum estradiol levels often associated with perioral pigmentation. All boys were young (mean: 6,8y), all had gynecomastia, most often the presenting symptom, with high estradiol levels. Most of the patients had perioral pigmentation and many Evidence of Evidence of familial Peutz-Jeghers Syndrome was available in only 8 cases. 20 patients had bilateral enlarged testis, with no discrete mass, and multiple echogenic foci on testicular ultrasound. 2 patients has unilateral enlarged testis, with discrete mass. In 19 patients, Sertoli Cell lesions were entirely intratubular, whereas 7 patients had 9 invasive Sertoli Cell Tumors, associated to Intratubular neoplasia. When extra tubulat foci were present they were similar to intratubular foci, and when performed, stained positively for antimullerian hormone and inhibin. Follow up was not available for all 26 patients but when available was indolent with no metastasis. Pathology of Sertoli Cell proliferations in boys with with Peutz-Jeghers Syndrome Sertoli cell proliferation of the testis is totally different from sex cord tumor observed in the ovary of girls with Peutz-Jeghers Syndrome. Venara et al (2001) prefer to term the intra tubular lesion "intra tubular Sertoli cell proliferations", due to their indolent course. Ulbright et al consider these lesions as "Intratubular Large Cell Hyalinizing Sertoli Cell neoplasms of the testis " because of their occasionsal progression to an invasive tumor, but agrees that conservative management is possible in most. The congenital gene defects might trigger a cascade of intracellular events that leads to overexpression of aromatase in Sertoli cells, favoring the development of Intratubular Large Cell Calcifying Sertoli Cell Neoplasia. Overexpression of aromatase in Sertoli cells is responsible for estrogenic manifestations. Aromatase has the capacity to use testosterone as substrate for the synthesis of estradiol, leading to elevation of its serum level and gynecomastia as its usual presenting feature. High growth velocity and advanced skeletal maturation are also consequence of estradiol elevation and important to reduce by treatment. Surgical treatment of gynecomastia can be necessary in some cases. Scattered giant seminiferous tubules, often in clusters, contain proliferating large Sertoli cells which replaced all germ cells and fill in the lumen. Enlarged Sertoli cells have pale to eosinophilic cytoplasm, round, regular nuclei, small nucleoli. The affected tubules are surrounded by thickened multi layered basement membrane, sending invaginations into the lumen, causing round hyalinized deposits. Focal intratubular calcifications were present in only 6 intratubular proliferations, but raise the question of Large Cell Calcifying Sertoli Cell tumors. 6/9 invasive tumors reported in the literature had foci of calcifications but differed from Large Cell Calcifying Sertoli Cell tumors. It appeared to Ulbright that only 2 tumors in one patient had the morphology of Large Cell Calcifying Sertoli Cell tumors. Others had closely packed tubules but lacked a conspicuous stroma. Our case presents with only intratubular Sertoli cell proliferation, no extra tubular foci. Whatever the denomination of the Sertoli Cell proliferation, all patients with Peutz Jeghers Syndrome and Sertoli cell lesions whose follow up was known did well, with a very long follow up for some of them. It leads to conclude that Sertoli Cell proliferations in Peutz-Jeghers Syndrome are remarkably indolent and justify conservative management by careful follow up rather than orchidectomy. Differential Diagnosis 1) Other intratubular testicular tumors are present in Carney Syndrome but there are some differences. Both in Peutz-Jeghers Syndrome and in Carney Syndrome, patients may develop bilateral multifocal intratubular proliferations of Large Sertoli Cells but Peutz-Jeghers patients have a greater degree of tubular enlargement, have more frequent basement membrane deposits and do not show as frequent or extensive calcifications. 2) Sertoli cell nodules (non neoplastic lesions commonly identified in cryptorchid testis) share patchy distribution, intratubular proliferation, and globular basement membrane deposits. But proliferation consists of small fetal Sertoli cells and contain spermatogonia (germ cells are absent in the Peutz-Jeghers lesion). 3) Gonadoblastoma usually develop on dysgenetic gonads. 40% are bilateral. The tumor is composed of germ cells with seminoma-like features intermixed with immature Sertoli cells. Rounded deposits of basement membrane are surrounded by the sex cord cells. 4) Sex cord tumor with annular tubules is the term used to describe the distinctive ovarian tumors in Peutz-Jeghers patients. The antipodal arrangement of sex cord cell around basement membrane deposits and typical calcifications present in the ovarian tumor is lacking in the testicular tumor of the boys with this syndrome. Nevertheless there are similarities between these 2 lesions. References Alikasifoglu A, Gonc EN, Akcoren Z, Kale G, Ciftci AO, Senocak ME, Yordam N : Feminizing Sertoli cell tumor associated with Peutz-Jeghers. J Pediatr Endocrinol Metab 2002 ; 15 : 449-52. Amos CI, Keltheri-Cherert MB, Sabripour M, Wei C, McGarrity TJ, Seldin MF, Natlons L, Lynch PM, Pidder HH, Friedman E, Prazier ML : Genotype-phenotype correlations in Peutz-Jeghers syndrome. J Med Genetics 2004 ; 41 : 327-33. 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