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Malignant testicular neoplasms Type Features Germ cell (95%)Seminoma• Retain features of spermatogenesis • β-hCG, AFP usually negative Nonseminoma• ≥1 partially differentiated cells: yolk sac, embryonal carcinoma, teratoma, and/or choriocarcinoma • β-hCG, AFP usually positive Stromal (5%)Leydig• Often produces excessive estrogen (gynecomastia) or testosterone (acne) • Can cause precocious puberty Sertoli• Rare • Occasionally associated with excessive estrogen secretion (eg, gynecomastia) AFP = alpha-fetoprotein. This patient with a testicular mass, gynecomastia, and elevated estrogen levels likely has a Leydig cell tumor, the most common type of testicular sex cord stromal tumor. These tumors arise from supporting cells of the testis such as Leydig, Sertoli, and granulosa cells; they account for approximately 5% of testicular tumors (germ cell tumors account for ~95%), arise in a wide range of ages, and have no clearly defined risk factors. Leydig cells are the primary source of testicular testosterone but are also capable of generating estrogen. Therefore, Leydig cell tumors often present with endocrine manifestations due to excessive estrogen (eg, gynecomastia, loss of libido, erectile dysfunction) or testosterone (eg, acne, hirsutism). Examination frequently reveals a testicular mass, which is typically confirmed by bilateral scrotal ultrasound. In contrast to many germ cell tumors, Leydig cells do not generally produce serum tumor markers such as β-hCG or alpha-fetoprotein (AFP). However, the generation of estrogen or testosterone often leads to FSH and LH suppression. (Choices A, D, and E) Choriocarcinoma, teratoma, and yolk sac tumors are nonseminomatous germ cell tumors. They typically present with a painless, firm testicular mass. However, they often produce β-hCG (particularly choriocarcinoma) or AFP (particularly yolk sac tumors) in addition; estrogen production is rare, so feminization is uncommon. (Choice C) Seminoma is a germ cell tumor that does not usually produce β-hCG, AFP, or estrogen. Therefore, feminization would be atypical. Most seminomas present with a painless, unilateral testicular mass or swelling. TAKE HOME MESSAGE Leydig cell testicular tumors often cause feminization (eg, gynecomastia) due to the production of estrogen by tumor cells. This frequently causes secondary inhibition of FSH and LH. Serum tumor markers (eg, β-hCG, AFP) are not usually elevated.

A 35-year-old man comes to the office due to a progressive increase in breast size over the past 6 months. He is sexually active, has no chronic medical conditions, and takes no medications. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. BMI is 28 kg/m². Gynecomastia with mild bilateral breast tenderness is present. Genitourinary examination reveals a 1-cm nodule in the right testis. The examination is otherwise normal. Laboratory results are as follows: LH: 3 U/L (normal: 6–23 U/L) FSH: 2 U/L (normal: 4–25 U/L) Testosterone: 270 ng/dL (normal: 300–1,000 ng/dL) Estradiol: 115 pg/mL (normal: 20–60 pg/mL) β-hCG: undetectable Alpha-fetoprotein: undetectable

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Proper breastfeeding technique promotes maternal comfort, ensures adequate infant nutritional intake, and facilitates long-term breastfeeding. Most breastfeeding patients experience nipple pain in the immediate postpartum period as they become accustomed to nursing 8-12 times/day or more, but this typically resolves after a few weeks. Nipple pain that worsens and persists between feedings is commonly due to nipple injury caused by poor infant positioning and improper latch-on technique. On examination, patients can have open, linear areolar abrasions that cause a bloody-appearing nipple discharge, bruising, cracking, and blistering may also be present. Breast engorgement, as seen in this patient with bilateral, diffusely tender, and engorged breasts, can also develop because nipple pain limits breastfeeding. Initial management is with the observation of breastfeeding and patient education. Nipple injury is a significant risk factor for multiple adverse outcomes (eg, plugged milk ducts, mastitis, breast abscess), which often lead to premature cessation of breastfeeding. (Choice A) Lactational mastitis is caused by bacterial overgrowth of stagnant milk in blocked ducts; it is a common cause of breast pain in breastfeeding patients. In contrast to this patient, those with lactational mastitis typically have fever and localized warmth or erythema over a single breast. (Choice B) Candida mastitis can be caused by spread from infant oral flora. Patients typically have nipple pain that radiates across the breast with latching; however, the pain is described as sharp and shooting and is usually out of proportion to the examination. In addition, it is typically unilateral, and the affected breast often has flaky, scaling skin over the nipple. (Choice C) Inflammatory breast cancer can cause unilateral, not bilateral, breast pain and tenderness. Patients typically have a breast mass with associated skin thickening and erythema (peau d'orange appearance) with axillary lymphadenopathy, which is not seen in this patient. (Choice D) An intraductal papilloma, a papillary tumor involving the breast duct, typically presents with bloody nipple discharge but no associated breast pain. TAKE HOME POINT Persistent nipple pain with breastfeeding is typically due to nipple injury, which can present with bilateral nipple abrasions and bloody nipple discharge. The most common underlying causes are poor infant positioning and improper latch-on technique.

A 39-year-old woman, gravida 1 para 1, comes to the office due to breast pain. She had an uncomplicated vaginal delivery a week ago and is breastfeeding her infant. Four days ago, the patient began to have bilateral nipple soreness with breastfeeding. However, for the past few days, the pain has worsened, is present between feeds, and has prevented breastfeeding. She has also developed bloody nipple discharge. The patient's pregnancy was complicated by gestational diabetes mellitus, but otherwise, she has no chronic medical conditions. Temperature is 37.5 C (99.5 F). Bilateral nipples and areolae have open, bloody, linear abrasions. The breasts are diffusely engorged and mildly tender to palpation, but there are no palpable masses or lymphadenopathy. The remainder of the examination is unremarkable.

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