Announcement

Announcement Module
Collapse
No announcement yet.

Unclassified sex cord stromal tumor

Page Title Module
Move Remove Collapse
X
Conversation Detail Module
Collapse
  • Filter
  • Time
  • Show
Clear All
new posts

  • Unclassified sex cord stromal tumor

    Long time lurker and (almost) first time poster checking in with my story, that will hopefully be helpful to others.

    I first found a lump in my left testicle sometime around May or June of 2018 after discovering an unrelated small movable marble sized lump on my ribs (dermatologist and PCP diagnosed as a lipoma). After some Dr. Googling I was pretty sure it was an epididymal cyst and since I had an appointment with my primary care physician scheduled for early August, I waited for that visit to go in for a consultation.

    He thought it was likely a cyst as well, but scheduled me for an ultrasound a couple of weeks later. I had the ultrasound, and when I received a phone call from my doctor's office that same day a few hours later I knew it was likely something more serious than a cyst.

    He referred me to the urological surgical oncology clinic, where I met with the surgeon who confirmed it was likely testicular cancer and scheduled me for a blood tests, a CT scan, chest x-ray and scheduled me for surgery.

    Blood tests came back negative for tumor markers, CT scan and chest x-ray was clean.

    I had my surgery on September 6, 2018 at 7:30 am and was feeling well enough to leave the hospital before 10:00 am the same morning. I woke up from surgery with a little nausea and pain, received a single opioid painkiller and some anti-nausea medication and was dressed and messaging my wife that I was bored and to pick me up at 9:14 am. Recovery has been uneventful and smooth, I had surgery for a right-side inguinal hernia back in the early aughts so I knew what to expect. Stayed away from opioid pain killers, and used the occasional ibuprofen and icing to manage the pain.

    After the surgery, the surgeon's assistant called me to reschedule my post-op visit because my pathology report wasn't yet prepared so I finally went in for the post-op visit a little before three weeks post-op where the surgeon said everything was healing well but that I had a very unusual tumor and that he would be referring me to a medical oncologist to handle my post-operative treatment plan.

    The pathology report is a total of five pages long, with the final diagnosis being an unclassified sex cord stromal tumor with spindle cells, 1.7cm.

    The surgeon said that there aren't well-established guidelines for active surveillance as in the case of classical seminomas or NGCTs. In the pathology report, they called out the small size (1.7 x 1.4 cm) and lack of necrosis or lymphovascular invasion as favorable features but call out “elevated mitotic activity [that] may portend a risk for recurrence.” This specific kind of tumor is malignant in approximately 10-20% of adults, but hopefully I've caught it early enough that all I will need is surveillance even though I have one of the risk factors for malignant potential.

    Since then I'm in a holding pattern waiting for my next visit and have gone through a crash course in sex cord stromal tumors, reading all of the journal entries and resources I can find on this uncommon diagnosis that aren't behind a paywall (if anybody has access to journals through their university, I would love to get a few PDFs from you). I've already contacted the International Ovarian and Testicular Stromal Tumor Registry (https://www.otstregistry.org) and will be sending them my file as well.

  • #2
    Afraid I know absolutely nothing about sex cord stromal tumors other than what you've said. I can't recall another case here, so sorry if no one is jumping in with tons of information. However, there s no doubt in my mind that whatever information you provide may well help the next person with a similar Dx, so please, keep us posted as you find out more.

    Dave
    Jan, 1975: Right I/O, followed by RPLND
    Dec, 2009: Left I/O, followed by 3xBEP

    Comment


    • #3
      Hi Sayhey,

      Like you,I had a Stromal Tumor, (Sertoli) and am all too familiar with the 10% to 20% malignancy chance. I have been searching for papers myself for the last 18 months or so, so if I come across any,I would be more than happy to send them your way. Also I am hoping to follow Dave's suggestion, hopefully I will post my pathology info in the next day or two.

      Best,
      ​Mark
      3-21-2017 Mass found on left testicle at work-medical exam
      3-28-2017 GP confirms mass, refers to Urologist the next day
      3-29-2017 Urologist visit, US, I/O scheduled
      4-05-2017 I/O
      4-11-2017 Pathology returns Sertoli Cell Tumor, NOS
      4-12-2017 CT All Clear
      6-06-2017 Bone Scan All Clear
      9-25-2018 CT All Clear

      Comment


      • #4
        I've got a paper copy of my pathology report (it's five pages long) and I'll post it once I get it in digital form in my online patient portal.

        Elevated mitotic activity is my only risk factor (the cut off is greater than 3 or 5 depending on the paper I've read, and my tumor had up to 10 mitoses per 10 high power fields).

        Comment


        • #5
          Below is my pathology report. I've removed the clinical history since I detailed it above, and edited out the name of what was likely the supervising doctor for their privacy.

          FINAL PATHOLOGIC DIAGNOSIS


          Left testicle and spermatic cord, radical orchiectomy:
          - Testis: Unclassified sex cord stromal tumor with spindle cells, 1.7
          cm; see comment.
          - Spermatic cord: No significant pathologic abnormality.


          COMMENT:
          Sections from the testis show a well circumscribed mass that consists
          predominantly of a cellular spindle cell proliferation growing in a
          somewhat fascicular pattern. The cells contain moderate to focally
          abundant eosinophilic cytoplasm and ovoid to spindle nuclei that are
          hyperchromatic and contain prominent eosinophilic nucleoli. Brisk
          mitotic activity is present, up to 10 mitoses per 10 high power fields.
          Subtle intermixed tubular structures and Sertoliform areas are
          identified. There are scattered variably prominent foci of intermixed
          round to ovoid cells with abundant clear cytoplasm and round nuclei with
          inclusions. Also noted at the periphery are occasional seminiferous
          tubules, some with a mix of the clear round cells and the dark spindle
          cells. The surrounding testicular parenchyma shows evidence of atrophy
          in the form of tubular hyalinization and Leydig cell hyperplasia. No
          definitive germ cell neoplasia in situ is identified.
          Based on the morphology, the differential diagnosis could include a
          mixed germ cell and sex cord stromal tumor, an unusual pure germ cell
          tumor and a pure sex cord stromal tumor, amongst others.
          Immunohistochemical studies were necessary to evaluate this case and
          establish the correct diagnosis. The following immunohistochemical
          stains were performed and evaluated on A2:

          - OCT4: Negative.
          - SALL4: Negative.
          - Keratin: Patchy positive.
          - Chromogranin: Negative.
          - Synaptophysin: Negative.
          - Inhibin: Patchy positive.
          - Calretinin: Focal positive in spindle cells, positive in round cells
          with clear cytoplasm.
          - SF-1: Patchy positive.
          - FOXL2: Positive.
          - SMA: Positive.
          - Desmin: Patchy positive.
          - S-100: Patchy positive.
          - Melan-A: Negative.

          In addition a reticulin stain shows staining around nests of cells (in a
          background of staining around individual cells).

          Overall the morphology and immunoprofile is most supportive of a sex
          cord stromal tumor. We considered various possibilities including a
          Sertoli cell tumor, Sertoli-Leydig cell tumor, granulosa cell tumor and
          some unusual tumors such as myoid gonadal stromal tumor and spindle
          Leydig cell tumor but ultimately feel that this unusual tumor is best
          categorized as a sex cord stromal tumor, unclassified, with spindle
          cells.
          The prognosis of these tumors is difficult to predict and while the
          small size and lack of necrosis or lymphovascular invasion are favorable
          features, the elevated mitotic activity may portend a risk for
          recurrence. Therefore clinical follow up is recommended.
          Dr. [name removed] reviewed this case and agrees with the diagnosis.

          Laterality: Left.
          Focality: Unifocal.
          Tumor size: 1.7 x 1.4 cm.
          Tumor histologic type: Sex cord stromal tumor, unclassified, with
          spindle cells.
          Tumor extension: Tumor limited to testis.
          Spermatic cord margin: Uninvolved by tumor.
          Other margin(s): Negative.
          Lymphovascular Invasion: Not identified.
          Regional lymph nodes: No lymph nodes submitted.
          Additional pathologic findings: Atrophy.

          Pathologic stage classification (pTNM, AJCC 8th Edition): pT1NX.
          Pre-orchiectomy serum tumor markers: AFP, HCG and LDH within normal
          limits.
          Post-orchiectomy serum tumor markers: Not known.
          Serum tumor marker stage (S): Not known.
          AJCC prognostic stage group: Not known.

          Specimen(s) Received

          A:1) Left Testicle - perm.

          Gross Description

          The case is received fresh in one part and is labeled with the patient's
          name, medical record number, and additionally labeled "left testicle"
          and consists of one testicle and attached spermatic cord (43.2 g,
          spermatic cord: 9 x 2 x 1 cm, testicle: 4.1 x 2.9 x 2.7 cm, epididymis
          6.2 x 1.8 x 0.4 cm, and appendage 1.2 x 1 x 0.7 cm). The tunica
          vaginalis is intact. There is a pale yellow, firm mass in the parenchyma
          of the testicle (1.7 x 1.4 x 1.1 cm) that abuts the tunica albuginea but
          does not invade, and is 0.1 cm from the tunical vaginalis. The remainder
          of the parenchyma is pink colored and soft. The epididymis is soft and
          grey, the tunica albuginea is pale grey, smooth, with no masses or
          adhesions. The tunica vaginalis is smooth and uninterrupted.

          Comment


          • #6
            I'd like to help you out with the papers. Please feel free to send me the titles of what you are looking for.

            Comment


            • #7
              Just posting an update to my case.

              Had my first appointment with my GU oncologist today, but before that I was able extremely lucky to be able to consult with Dr. Einhorn and even meet and discuss my case with him in person. I also was able to read most if not all of the available literature out there in the journals about testicular SCSTs.

              While saying that going on surveillance would not be incorrect per se in my case, Dr. Einhorn strongly recommended that I get an RPLND as surgery would be the only likely way to cure the disease if it were to spread if it had not already.

              I forwarded his recommendations to my GU oncologist through my hospital's new patient coordinator, and my first visit today was more of a discussion than a typical visit. She concurred with Dr. Einhorn's recommendations, and said while it was ultimately my decision to decide between surveillance or the surgery she seemed to recommend the latter. I will be able to go on a reduced surveillance schedule post-op, since with the high right of mitotic activity and undifferentiated/unclassified diagnosis she would have to treat it as potentially aggressive and malignant.

              The RPLND will also be useful as a staging tool, even if finger's crossed all of the nodes removed come back with no evidence of disease.

              I'll keep updating, and if anybody stumbles across this thread with a similar diagnosis I'd be happy to answer any questions.

              Comment


              • #8
                Glad you were able to speak with Dr Einhorn and have a good look at the available literature. You are in my thoughts, looking forward to seeing all clear reports!

                Best,
                Mark
                3-21-2017 Mass found on left testicle at work-medical exam
                3-28-2017 GP confirms mass, refers to Urologist the next day
                3-29-2017 Urologist visit, US, I/O scheduled
                4-05-2017 I/O
                4-11-2017 Pathology returns Sertoli Cell Tumor, NOS
                4-12-2017 CT All Clear
                6-06-2017 Bone Scan All Clear
                9-25-2018 CT All Clear

                Comment


                • #9
                  I am glad that you were able to meet with Dr. Einhorn, he is awesome isn't he? I know it is a tough choice but given that the treatments for stromal tumors is not that affective and being unclassified and high mitotic rate, there is really no data that I have seen, would lend me more toward the RPLND too. The review that I had seen from the National Cancer Database would lead me more towards using an abundance of caution and doing the RPLND https://www.jurology.com/article/S00...067-2/abstract but it is very much a personal decision with no perfect answer except for what is right for you.

                  Mike
                  Oct. 2005 felt lump but waited over 7 months.
                  06.15.06 "You have Cancer"
                  06.26.06 Left I/O
                  06.29.06 Personal Cancer Diagnosis Date: Got my own pathology report from medical records.
                  06.30.06 It's Official - Stage I Seminoma
                  Surveillance...
                  Founded the Testicular Cancer Society
                  6.29.13 Summited Mt. Kilimanjaro for 7th Cancerversary

                  For some reason I do not get notices of private messages on here so please feel free to email me directly at mike@tc-cancer.com if you would like to chat privately so as to avoid any delays.

                  Comment


                  • #10
                    Thanks for the kind words, and thoughts. I'm having the normal "scanxiety" ahead of my CT scans and chest X-ray next week, before I meet with the surgeon the week after.

                    I've compiled a list of relevant journal articles, along with some of my notes, that should be of relevance to anybody researching sex cord stromal tumors. To anybody with the same or similar diagnosis, if you'd like to reach out to discuss and just talk feel free to post or send me a message.

                    Does retroperitoneal lymph node dissection have a curative role for patients with sex cord-stromal testicular tumors?
                    Mosharafa AA, Foster RS, Bihrle R, Koch MO, Ulbright TM, Einhorn LH, Donohue JP
                    https://www.ncbi.nlm.nih.gov/pubmed/12910519



                    Clinical Outcomes of Local and Metastatic Testicular Sex Cord-Stromal Tumors
                    Silberstein JL, Bazzi WM, Vertosick E, Carver BS, Bosl GJ, Feldman DR, Bajorin DF, Motzer RJ, Al-Ahmadie H, Reuter VE, Sheinfeld J.
                    https://www.ncbi.nlm.nih.gov/pubmed/24518791



                    Pathologic Risk Factors for Occult Metastatic Disease in Adolescent and Adult Patients with Stage I Testicular Stromal Tumors
                    Rove KO, Maroni PD, Cost CR, Fairclough DL, Giannarini G, Harris A, Schultz KA, Cost NG



                    Pathologic Risk Factors in Pediatric and Adolescent Patients With Clinical Stage I Testicular Stromal Tumors
                    Rove KO, Maroni PD, Cost CR, Fairclough DL, Giannarini G, Harris AK, Schultz KA, Cost NG
                    https://www.ncbi.nlm.nih.gov/pubmed/26479987



                    Sex Cord Stromal Testicular Tumors: A Clinical Series—Uniformly Stage I Disease
                    J.M. Featherstone, H.S. Fernando, J.M. Theaker, P.D. Simmonds, M.C. Hayes, G.M. Mead
                    https://www.jurology.com/article/S00...09)00060-3/pdf



                    Wessex regional cancer center in the UK, 38 men older than 18 years with sex cord stromal testicular tumors over a 25-year period fro 1982-2006. All patients were treated with removal of primary tumor only. No patients developed metastatic disease.



                    Editorial Comment
                    David A. Diamond
                    Department of Urology, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts
                    https://www.jurology.com/article/S00...345-0/abstract



                    These authors review a considerable experience with clinical stage I SCS testicular tumors, which proved to be nonmetastatic, and compared this to a literature based series of metastatic SCS testis tumors to determine predictors of malignant spread. Based on this comparison they conclude that routine prophylactic RPLND should not be performed in the absence of radiological evidence of solitary retroperitoneal disease. I would argue that they have identified histological predictors of aggressiveness and should use them to determine the applicability of RPLND whether or not retroperitoneal nodes are visualized.



                    Metastatic Relapse After Initial Clinical Stage I Testicular Leydig Cell Tumor
                    Nicholas G. Cost, MD, Paul D. Maroni, MD, and Thomas W. Flaig, MD
                    http://www.cancernetwork.com/oncolog...dig-cell-tumor



                    70-year old healthy man presented with 2.1cm Leydig cell tumor with moderate (4-5 mitoses per HPF), as well as invasion of spermatic cord. No LVI, cellular atypia, or tumor necrosis. CT scans were negative. Serum testosterone and Inhibin levels were normal (can be elevated in LCT).



                    Diagnosis was Stage 1B LCT.



                    2 years after initial presentation CT scans revealed a 1.2-cm right inguinal lymph node and a 1-cm left para-aortic lymph node. No action was taken, and a follow up 3 months later showed an increase in size.



                    Patterns of Care and Survival Outcomes for Malignant Sex Cord Stromal Testicular Cancer: Results from the National Cancer Data Base.
                    Banerji, JS; Odem-Davis, K; Wolff, EM; Nichols, CR; Porter CR
                    https://www.ncbi.nlm.nih.gov/pubmed/27036305



                    EAU Guidelines on Testicular Cancer
                    P. Albers (Chair), W. Albrecht, F., Algaba, C. Bokemeyer, G. Cohn-Cedermark, K. Fizazi, A. Horwich, M.P. Laguna, N. Nicolai, J. Oldenburg
                    https://uroweb.org/wp-content/upload...cer-2016-1.pdf



                    9.4 Treatment of Leydig- and Sertoli cell tumours

                    Prophylactic RPLND is unjustified for patients with clinical stage I disease without high-risk features [314].



                    9.5 Follow-up of Leydig- and Sertoli cell tumours

                    Without clinical signs of malignancy, an individualised surveillance strategy after orchidectomy is recommended in patients with one, or more, pathological features of malignancy. Follow-up is recommended in all high risk patients; every 3 to 6 months with physical examination, hormone assays, scrotal and abdominal ultrasonography, chest radiography, and CT [293].



                    9.8 Other sex cord/gonadal stromal tumours

                    Sex cord/gonadal stromal tumours may be incompletely differentiated or in mixed forms. There is limited experience with incompletely differentiated sex cord/gonadal stromal tumours and no reported cases of metastasis [32]. In mixed tumour forms, all the histological components should be reported. However, the clinical behaviour most likely reflects the predominant pattern or the most aggressive component of the tumour [320].



                    [314. Featherstone, J.M., et al. Sex cord stromal testicular tumors: a clinical series--uniformly stage I disease. J Urol, 2009. 181: 2090. http://www.ncbi.nlm.nih.gov/pubmed/19286222]



                    [293. Suardi, N., et al. Leydig cell tumour of the testis: presentation, therapy, long-term follow-up and the role of organ-sparing surgery in a single-institution experience. BJU Int, 2009. 103: 197. http://www.ncbi.nlm.nih.gov/pubmed/18990169]



                    [32. Jing, B., et al. Metastases to retroperitoneal and pelvic lymph nodes: computed tomography and lymphangiography. Radiol Clin North Am, 1982. 20: 511. http://www.ncbi.nlm.nih.gov/pubmed/7051132]



                    [320. Perito, P.E., et al. Sertoli-Leydig cell testicular tumor: case report and review of sex cord/gonadal stromal tumor histogenesis. J Urol, 1992. 148: 883. http://www.ncbi.nlm.nih.gov/pubmed/1512847]



                    Adult type granulosa cell tumor of the testis with a heterologous sarcomatous component: case report and review of the literature
                    Thomas EO Schubert, Robert Stoehr, Arndt Hartmann, Sabrina Schöne, Mathias Löbelenz and Gregor Mikuz
                    https://diagnosticpathology.biomedce...746-1596-9-107



                    Malignant undifferentiated sex cord-stromal testis tumor with brain metastasis: Case report
                    Urologic Oncology: Seminars and Original Investigations, Volume 26, Issue 1, January–February 2008, Pages 53-55
                    Priya G.Kumaravelu, M.D., Sandra Vella M.D., J. Edson Pontes, M.D., Elisabeth I.Heath M.D.
                    https://www.sciencedirect.com/scienc...07814390600299


                    Comment

                    Working...
                    X