Leydig cell tumor of the testis with azoospermia and elevated delta4 androstenedione: case report

Background Secreting interstitial cell (Leydig cell) tumors are rare. In adults, the clinical picture and steroid levels are variable. Case presentation This paper presents a case of left testicular tumor, showing azoospermia with normal serum level of total testosterone, collapsed FSH and LH, and high delta4 androstenedione. Histopathological investigation revealed a Leydig cell tumor. TESE allowed spermatozoa extraction and freezing. Testicular histology found hypospermatogenesis and germ-cell aplasia with interstitial fibrosis. Surgical resection of the tumor resulted in normalization of gonadotropins and fall in serum delta4 androstenedione to subnormal levels in the postoperative period confirming that the tumor was secreting delta4 androstenedione. It was hypothesized that high delta4 androstenedione resulted in intra tumoral 17 β-HSD overtaken by delta4 androstenedione or that 17 β-HSD activity in the tumor was different from that of normal Leydig cells. Three months after surgery sperm analysis found a complete recovery of spermatogenesis. A spontaneous pregnancy occurred 3 months after surgery and a girl was born. Conclusions In this case, the diagnosis of testicular Leydig cell tumor secreting delta4 androstenedione was made in a context of azoospermia.


Case presentation
A 44 year old man was referred to our clinic for secondary infertility; he had no medical or surgical history or medical treatment. He was a butcher and married.
In 2009, he consulted another medical center for primary infertility. His medical history included no testicular trauma, no inguino scrotal surgery, no cryptorchidism, no professional exposure, no tobacco, no alcohol, or drug consumption. Semen analysis is summerized in Table 1.
Scrotal ultrasonography (  In 2014 the patient consulted a doctor in our clinic as he wished to have another child. Semen analyses showed strict azoospermia with normal volume (Table 1).
Physical examination showed a normal andrological development, testes were present in the scrotum, a slightly indurated mass could be felt in the upper pole of the left testis. Right testis was hypotrophic, seminal conducts were felt. There was neither gynecomastia nor any sign of hypercortisolism.
Serum analyses are described in Table 3. Total testosterone was measured by RIA using the Coat-A-Count Kit (Siemens Diagnostics, Inc., Los Angeles, CA, USA). The assay's limit of quantification was 0.14 nmol/L (0.04 ng/mL) and the interassay CV was between 5.9 and 11.0 % for a range of concentrations between 0.76 and 13 ng/mL. The FSH, LH, and estradiol were measured using chemiluminescent, two-site immunoassays on a multiparameter analyzer NF not feasible (Architect; Abbott Laboratories). Delta4 androstenedione was measured in duplicate by radioimmunoassay using a kit provided by Beckman Coulter Immunotech. The percentage of testosterone crossreactivity was 0.5 % with androstenedione and 0.02 % with estradiol. A marked increase in androstenedione levels and suppressed gonadotropin levels were found which are likely to contribute to the failure of spermatogenesis. Normal Dehydroepiandrosterone Sulfate argues against adrenal hyperandrogenism.
Abdomen and Thorax Computed Tomography (CT) imaging were normal (no adrenal gland abnormality and no secondary lesions).
The committee on tumoral diseases agreed on the decision to perform a testis-sparing surgery with extemporaneous histological examination. We decided to perform a testicular sperm extraction (TESE) at the same time. TESE allowed spermatozoa extraction with freezing.
Surgical resection of the tumor (Fig. 1) allowed a tumor of 35 × 30 × 17 mm to be removed.
Immunostaining was performed on an automated immunostainer (Benchmark, Ventana, France) with antibodies to Inhibin A (Ventana, prediluted, pretreatment: EDTA pH 7.8 for 60 min) and to SALL4 (Sigma, Dilution: 1/1500, pretreatment: EDTA pH 7.8 for 60 min). All tumor cells were diffusely and strongly stained with antibody to Inhibin A corresponding to Leydig cell tumor and were completely negative to antibodies to SALL4 showing that there was no germ cell contingent (Figs. 2, 3 and 4).
Surgical resection of the tumor (Fig. 1) resulted in normalization of gonadotropins and fall in serum delta4 androstenedione to subnormal levels in the postoperative period confirming that the tumor was secreting delta4 androstenedione (Table 4).
We hypothesized that high delta4 androstenedione resulted in intra tumoral 17 β-HSD overtaken by a delta4 androstenedione excess or that 17 betaHSD activity in the tumor was different from that of normal Leydig cells (Fig. 6).
Scrotal ultrasonography 3 months after surgery described a normal right testis which had increased in size (volume 15 mL) and a left testis with a rearranged aspect secondary to surgery ( Table 2).
Three months after surgery semen analyses showed a complete recovery of spermatogenesis (Table 1). A spontaneous pregnancy occurred, 3 months after surgery and a girl was born in 2015 (3450 g).

Discussion
To the authors' knowledge only one case of androstenedione secreting testicular Leydig cell tumors associated  IU international unit ng/mL nanogram/milliliter pmol/L picomole/liter IU/L international unit/liter pg/mL picogram/milliliter μmol/L micromole/liter μg/L microgram/liter μg / 100 mL : microgram/100 milliliter with azoospermia has been reported previously [2]. In that case, serum levels of testosterone, dihydrotestosterone, 5α-androstane-3α,17βdiol and oestradiol were normal and oestrone was moderately increased. In contrast androstenedione was extremely elevated. Testosterone levels in the spermatic vein were decreased indicating a partial deficiency of 17β hydroxysteroid dehydrogenase in the tumoral tissue. Twenty-eight months after surgery, all sex steroids including androstenedione were normal. In the present case, total suppression of LH levels and almost complete suppression of FSH levels were associated with azoospermia, despite intratesticular testosterone secretion by the tumor, and azoospermia proved to be fully reversible within less than three months after tumor removal and normalization of hormone levels, which shows that normal secretion of gonadotropins, plays a major role in maintaining spermatogenesis. This appears to be in agreement with other (rare) reports of patients with Leydig cell tumors and reversible azoospermia, who did not suffer from other testicular disorders. Interestingly, in these previous reports, the patients were also found to have testosterone secreting Leydig cell tumors with undetectable [15] or markedly reduced [12] gonadotropin levels, which suggests that intratesticular secretion of testosterone by the tumor is not sufficient to prevent azoospermia in spite of marked suppression of LH and FSH secretion. The present paper shows that even with collapsed gonadotropin levels TESE allowed extraction of spermatozoa.  To convert serum testosterone values from ng/mL into system international (SI) units (nmol/L), multiply by 3.47