Large cell calcifying Sertoli cell tumour: molecular and immunohistochemical assessment of a series comprising non‐metastasising and metastasising neoplasms

Aims Large cell calcifying Sertoli cell tumour (LCCSCT) is a type of testicular sex cord‐stromal tumour that may occur sporadically or in the context of Carney complex and other genetic syndromes. A subset is clinically malignant, and the molecular mechanisms that drive such aggressive behaviour remain unknown. Methods and results We analysed 21 samples from 20 patients with LCCSCT (12 non‐metastasising and eight metastasising) using PRKAR1A immunohistochemistry (IHC) and next‐generation sequencing. All tumours except two (cases 17 and 20, both metastasising) demonstrated loss of PRKAR1A expression. Among 11 cases with interpretable sequencing results, all harboured pathogenic single nucleotide variants of PRKAR1A. Evidence of loss of heterozygosity (LOH) of PRKAR1A was present in all tumours with interpretable zygosity data, but the mechanisms of LOH were different for non‐metastasising and metastasising tumours. Non‐metastasising tumours demonstrated only copy‐neutral LOH, while metastasising tumours demonstrated a spectrum of mechanisms of LOH, including copy‐loss LOH, two concurrent mutations or copy‐neutral LOH. Relevant molecular findings in non‐metastasising LCCSCT were limited to PRKAR1A variants. In contrast, all metastasising LCCSCTs with interpretable data harboured additional pathogenic variants, including (but not restricted to) BRCA2 mutations with evidence of LOH and bi‐allelic CDKN2A/B deletions. Three patients harboured PRKAR1A variants of inferred germline origin, including one with Carney complex and two without known syndromic features. Conclusions This study further confirms that PRKAR1A IHC is a useful diagnostic tool for both non‐metastasising and metastasising tumours and suggests that molecular analyses can be helpful to identify non‐metastasising tumours with malignant potential in selected patients. Importantly, these results highlight that germline assessment could be beneficial for all patients presenting with LCCSCT. Large cell calcifying Sertoli cell tumours consistently harbour pathogenic PRKAR1A variants with evidence of loss of heterozygosity. Additional pathogenic variants were present only in metastasising cases.