Sertoli cell tumor is a rare sex cord-stromal tumor of the testis, comprising <1% of all testicular tumors. It originates from Sertoli cells, the supporting cells of seminiferous tubules. On ultrasonography, it typically appears as a small-to-medium, hypoechoic, well-defined mass that may contain calcifications. The vast majority are benign (88-90%); malignant variant is rare, characterized by large size, necrosis, and vascular invasion. Hormonal symptoms are less prominent than Leydig cell tumor but gynecomastia may be seen. Inhibin B elevation may provide diagnostic clue.
Age Range
20-50
Peak Age
40
Gender
Male predominant
Prevalence
Rare
Sertoli cell tumor is a sex cord-stromal neoplasm originating from Sertoli cells, the supporting cells of seminiferous tubules. Normal Sertoli cells support germ cell development, form the blood-testis barrier, and produce hormones such as inhibin B and AMH (anti-Müllerian hormone). Tumoral Sertoli cells may autonomously maintain these functions, and inhibin B elevation provides diagnostic clue. Large cell calcifying Sertoli cell tumor (LCCSCT) is a special variant that may be associated with Carney complex or Peutz-Jeghers syndrome. Calcifications on ultrasonography reflect dystrophic or psammomatous calcifications between tumor cells; this finding is particularly prominent in the LCCSCT subtype and develops as a result of hyalinized areas and collagen accumulation in the stroma. Malignant transformation is rare and associated with large size, necrosis, increased mitotic activity, and vascular invasion.
A well-defined intratesticular mass with calcifications on ultrasonography combined with normal serum AFP and beta-HCG levels is highly typical for Sertoli cell tumor (especially LCCSCT variant). This finding combination is critically important in distinguishing from germ cell tumors.
Sertoli cell tumor appears as a hypoechoic, well-defined intratesticular mass on ultrasonography. Calcifications are particularly prominent in the LCCSCT variant and may create acoustic shadowing. Calcification is less common in the classic type. Mass size is generally 1-5 cm. Homogeneous or mildly heterogeneous internal structure is seen. Sclerosing variant may appear more echogenic. Heterogeneity, necrosis, and irregular margins are seen in malignant variants.
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A hypoechoic, well-defined mass with calcification foci is seen in the testicular parenchyma; sex cord-stromal tumor should be considered.
Color Doppler demonstrates moderate intralesional vascularity in Sertoli cell tumor. Vascularity is generally less prominent than Leydig cell tumor. Vascular pattern may be regular or mildly irregular. No vascularity in calcified areas. Vascularity may increase in malignant variants with irregular pattern.
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Color Doppler examination demonstrates moderate intralesional vascularity in the mass.
On T2-weighted MRI, Sertoli cell tumor shows low-to-intermediate signal intensity. In LCCSCT variant, calcifications are seen as signal void areas. Fibrous stroma shows low T2 signal. Distinctly lower signal than normal testicular parenchyma.
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The mass shows low-to-intermediate signal on T2-weighted sequences with focal signal void areas consistent with calcifications.
On T1-weighted sequences, Sertoli cell tumor shows isointense signal. Moderate-to-prominent enhancement on contrast-enhanced series. Calcified areas show signal void on T1 as well. Sclerosing variant may show less enhancement.
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The mass shows isointense signal on T1-weighted sequences with moderate enhancement on contrast-enhanced series.
On DWI, Sertoli cell tumor shows mild-to-moderate diffusion restriction. ADC values may be higher than germ cell tumors. Calcified areas show signal void on DWI. More prominent restriction and lower ADC values may be seen in malignant variants.
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The mass shows mild-to-moderate diffusion restriction on DWI with signal void in calcified areas.
On CT, Sertoli cell tumor appears as a mass with prominent calcifications, especially in the LCCSCT variant. Calcifications may be coarse or fine, focal or diffuse. CT is superior to MRI in detecting calcifications. When used for staging, retroperitoneal lymphadenopathy is investigated.
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The testicular mass contains prominent calcifications on CT; large cell calcifying Sertoli cell tumor should be considered.
Criteria
Most common type. Tubular or solid growth pattern. Less calcification. Inhibin positive. Mostly benign.
Distinct Features
Homogeneous hypoechoic mass on US, minimal calcification. May be indistinguishable from Leydig tumor on imaging.
Criteria
Widespread intratumoral calcifications characteristic. May be bilateral and multifocal. Associated with Carney complex (30%) or Peutz-Jeghers syndrome. Occurs in young age.
Distinct Features
Prominent calcifications on US and CT are pathognomonic. Bilateral small calcified lesions suggest Carney complex. Prominent signal void areas on MRI.
Criteria
Rare variant. Dense fibrous stroma dominant. Minimal cellular component. Entirely benign behavior.
Distinct Features
May appear as isoechoic-hyperechoic mass on US (due to fibrous stroma). Low signal on all MRI sequences (collagen). Minimal enhancement.
Distinguishing Feature
Leydig cell tumor shows more prominent hypervascularity and gynecomastia/hormonal symptoms are more common. Calcification is more prominent in Sertoli. Inhibin B may be elevated in Sertoli, testosterone/estrogen elevated in Leydig.
Distinguishing Feature
Seminoma does not contain calcifications and is generally larger. Beta-HCG may be mildly elevated in seminoma. All germ cell markers normal in Sertoli tumor.
Distinguishing Feature
Epidermoid cyst shows 'onion ring' pattern and is completely avascular. Vascularity is present in Sertoli tumor and calcifications may be coarser.
Distinguishing Feature
Burned-out GCT appears as small calcified scar and may present with retroperitoneal mass/metastasis. Sertoli tumor has organized mass structure. Tumor markers may be elevated in burned-out.
Urgency
lowManagement
Benign: testis-sparing surgery (enucleation) with frozen section. Malignant: radical inguinal orchiectomy + RPLND. No effective chemotherapy for malignant variant. Genetic screening for Carney complex or Peutz-Jeghers if LCCSCT.Biopsy
Not NeededFollow-up
Annual scrotal US for contralateral testis. Inhibin B monitoring if initially elevated. Malignant: CT surveillance for metastases. LCCSCT: cardiac screening for Carney complex (myxomas).Sertoli cell tumor is predominantly a benign neoplasm treated with testis-sparing surgery. In LCCSCT variant, screening for Carney complex (cardiac myxoma, lentiginous pigmentation, endocrine tumors) and Peutz-Jeghers syndrome is recommended. Malignant variant is rare and requires aggressive surgery; no effective chemotherapy or radiation available.
Most Sertoli cell tumors (80-90%) are benign and can be treated with testis-sparing surgery. The large cell calcifying subtype is usually bilateral and multifocal in young patients and may be associated with Carney complex (cardiac myxoma, skin lesions, endocrine tumors) or Peutz-Jeghers syndrome — genetic counseling is recommended in this case. In malignant cases (10-20%), radical orchiectomy and retroperitoneal lymph node dissection are performed. Prognostic factors: size >5 cm, necrosis, vascular invasion, and high mitotic index.