Impalpable testicular tumors diagnosed by scrotal ultrasonography

Intrascrotal masses can be identified with a high degree of accuracy using scrotal ultrasonography. Ultrasound, however, is useful to identify occult and incidental testicular neoplasms, too. We report 2 cases of impalpable incidental testis germ cell tumors diagnosed by routine scrotal ultrasonography. One of the 2 patients had an incidental sequential second primary testicular germ cell tumor in the palpably normal testis, identified by routine follow-up ultrasound three months after contralateral radical orchiectomy.     

Scrotal ultrasonography: should it be used in routine evaluation of infertile men?

Several studies have suggested that male infertility and testicular cancer may have common aetiological factors. Scrotal ultrasonography (US) has an important role in the diagnosis of testicular tumours when not palpable by physical examination. In this study, we present two infertile men referred to our clinic. Patients were evaluated by a detailed physical examination, semen analyses and hormonal assessment. Both patients underwent scrotal US examination. Semen analysis of the patients revealed oligoasthenospermia in both patients. Scrotal US revealed hypoechoic masses in the left and right testes of both patients, which were nonpalpable by physical examination. Scrotal exploration and subsequent orchidectomy were performed. Histopathological examination revealed mixed germ cell tumour and Sertoli-Leydig cell tumour in case 1 and case 2 respectively. With these cases, we discussed the role of scrotal US in the routine diagnostic evaluation of infertile men.     

Primary solid tumors of the epididymis. Apropos of 4 cases of benign tumor and one case of malignant mesothelioma

Based on a series of 5 tumours of the epididymis, the authors recall the relative frequency of primary solid tumours of the epididymis. They present 2 benign mesotheliomas and discuss the various histogenetic theories for their development, one fibroma, one haemangio-fibro-leiomyoma and one malignant mesothelioma of the cord, invading the epididymis. These are rare tumours (Broth's review of the literature revealed 278 cases in the world, consisting of 209 benign tumours (75%) and 69 malignant tumours (25%). The most frequent benign tumour is the mesothelioma (75% of the benign tumours), formerly referred to as an "adenomatoid tumour". Its histogenesis is still controversial (epithelial or mesothelial origin). The mesothelial theory is the more widely accepted. According to the majority of authors, malignant mesothelioma of the epididymis does not exist, but our case of malignant tumour questions this concept. The other tumours consist of benign and malignant mesenchymal, epithelial or dysembryoplastic tumours. The borderline with spermatic cord tumours is not always easy to define. The authors recall the value of comparative scrotal ultrasonography for the topographical diagnosis of tumours of the epididymis and testicular tumours and the differential diagnosis with certain epididymal cysts.     

Management of the impalpable testis; the value of laparoscopy for subsequent treatment]

During a 5-year period between April 1984 and March 1989, we were unable to palpate 62 testes (56 child patients) at the time of diagnosis. An average of 10 months later, 51 testes (48 patients) still remained impalpable preoperatively. Of the two imaging techniques, computed tomography and ultrasonography, the former is rather superior to the latter for verifying the existence of the impalpable testis. However, careful palpation under anaesthesia results in the accurate location of the testis more often than either of those two imaging techniques. On the other hand, as an aid in management of the impalpable testis, laparoscopy offers the most useful information for use in later surgery. This is because we are able to see the spermatic vessel and the vas deferens intraabdominally, in addition to the abdominal testis. Thirty-six patients (39 testes), whose testes remained impalpable even under anaesthesia, underwent laparoscopy. In two cases, we were unable to perform laparoscopy successfully due to failed pneumoperitoneum. However, in all the other cases, the information which could be obtained was fully utilized during subsequent management. Of a total of 37 instances, 8 testes which were abdominal or just canalicular (pendulous) could be recognized. In addition, 4 more were found to have no spermatic vessel in the visual field and a further 4 had a vessel disappearing before reaching the internal ring. In the remaining 21, we were able to detect the spermatic vessel and the vas deferens. At 59 instances of exploratory surgery, a mere 11 testes, among 27 testes, could be fixed to the bottom of the scrotum, resulting in scrotal dimples lasting for several months in 2 cases. Another 14 testes were placed in the upper scrotal region, while 2 were left in the groin region subcutaneously for lack of any alternative site.     

Epididymal cysts in adolescents]

Epididymal tumours are uncommon in children and adolescents and are usually benign. Epididymal cyst is exceptionally reported in the literature, although it is certainly underdiagnosed. The authors report 3 cases of epididymal cyst in 3 children, 12, 14 and 16 years of age. These children presented with an uncomfortable scrotal mass and were treated by excision of the cyst in every case. The aetiology of epididymal cysts is unclear. It is probably a congenital abnormality related to hormonal disorders during embryonic life. Physical examination is very important, but not sufficient for the diagnosis and must be completed by scrotal ultrasonography, which shows an echo-free cystic epididymal structure. Despite ultrasonography, the differential diagnosis of other scrotal cystic masses and even some solid epididymal tumours, which may present all of the sonographic characteristics of a cyst, must be considered. The treatment of symptomatic epididymal cyst in children must be surgical. For asymptomatic cysts diagnosed by sonography, clinical follow-up to document stability of the mass is justified.     

Clinicopathological characteristics and non-adhesive organ culture of insulinomas.

BACKGROUND AND AIMS: Insulinoma is a very rare type of islet cell tumour, but nevertheless the most common endocrine tumour of the pancreas. We aimed at reviewing our clinical experience with this tumour type and to assess whether organ culture could be obtained from surgically resected insulinoma material. MATERIAL AND METHODS: All patients with insulinomas (6 men and 10 women) referred to Haukeland University Hospital between 1986 and 2006 were included in the study. Median age of onset was 53 years (range 21-74). Biochemical diagnosis was established during a 72 h fast test. Imaging and localization of the tumours were performed with intra-operative ultrasonography, endoscopic ultrasonography, CT-scan and/or transcutaneous ultrasonography. For six patients, organ cultures were set up from tumour tissue fragments. RESULTS: The annual incidence of insulinoma was 0.8 per million. The patients generally presented with non-specific, episodic symptoms, which often were mistaken for cardiovascular, neurological or diabetic disease and in some cases delayed the diagnosis with several years. Two patients had diabetes prior to the diagnosis of insulinoma. Patient weight gain was probably due to increased food intake, compensating for the hypoglycemia. Intra-operative ultrasonography detected all tumours correctly, whereas 73% were detected by endoscopic ultrasonography and 38% by CT scan. Five insulinomas were located in the head, eight in the body and three in the tail of the pancreas. All were removed by open-access surgery, eleven cases by resection and five by enucleation. One tumour was malignant with liver metastases and two patients had tumours defined as borderline. Insulinoma tissue fragments developed into spheroids during the first week of culturing and insulin secretion into the media was demonstrated. CONCLUSIONS: Insulinomas are rare and diagnostically challenging tumours. Intra-operative ultrasonography was superior to other imaging modalities to locate the lesion. In organ culture, insulinomas readily form spheroids which may be used to yield insight into beta-cell biology.     

Testicular and paratesticular tumours in children: 30 years' experience.

BACKGROUND: Testicular or paratesticular tumours in children are rare, making it difficult to achieve the best management for these life-threatening diseases. The aim of this study is to review patients during a 30-year period with these tumours and assess clinical aspects to improve management. METHODS: The records of 68 patients from 1967 to 1996 were reviewed with respect to age at diagnosis, affected sites, presentation, clinical diagnosis, operation, pathology and prognosis. RESULTS: The most common presentation was a painless scrotal mass (84%). The most common testicular tumour was mature teratoma (n = 27) followed by yolk sac tumour (n = 17). Thirteen patients had paratesticular rhabdomyosarcoma. Two teratocarcinomas, three leydig cell tumours, two sertoli cell tumours, one granulosa cell tumour, one fibroma, one gonadoblastoma, and one secondary tumour from acute myeloid leukaemia were found also. Testis-sparing surgery was performed in 21 of 33 patients with benign tumours (27 teratoma, three leydig cell tumours, two sertoli cell tumours, one fibroma), which caused no recurrence. Only two patients with rhabdomyosarcoma and one with mixed germ cell tumour died of their disease. CONCLUSION: Recent combined therapy with surgery and chemotherapy against primary testicular and paratesticular tumours has improved prognosis. Testis-sparing surgery should be considered for benign tumours.     

Routine scrotal ultrasonography during the follow‐up of patients with testicular cancer leads to earlier detection of asynchronous tumours and a high rate of organ preservation

Study Type – Diagnosis (case series)
Level of Evidence 4

OBJECTIVE

To compare outcomes of patients with asynchronous tumours detected before and after the introduction of scrotal ultrasonography (SUS) during routine follow‐up examinations.

PATIENTS AND METHODS

Since January 2001 SUS was also used during the follow‐up of patients with testicular cancer. A series of 16 consecutive patients with asynchronous bilateral testicular tumours diagnosed while still complying with routine follow up investigations were identified and divided into two groups; group A was diagnosed by palpation only, before 2001, and group B was diagnosed after 2000. The groups were compared statistically for the interval between asynchronous tumours, clinical stage, tumour diameter at the time of diagnosis and rate of testis‐sparing surgery.

RESULTS

All tumours in group A were diagnosed by palpation, but only two in group B were palpable at the time of diagnosis. The mean tumour diameter was statistically significantly smaller in group B (1.2 cm) than in group A (2.68 cm); testis‐sparing surgery was used in all of group B and only three patients in group A. After organ‐sparing surgery all patients had normal testosterone levels. All patients after organ‐sparing surgery had adjuvant scrotal radiotherapy because of germ cell tumour, and no patient had a local recurrence.

CONCLUSION

Our data indicate that using SUS for the remaining testicle in routine follow‐up visits of patients with testicular cancer leads to the earlier detection of smaller tumours and, consequently, a higher rate of organ preservation. The maintenance of physiological endocrine function might finally result in a better quality of life.     

Giant cell tumour of bone: its aggressiveness and potential for malignant change

Thirty cases of giant cell tumour of bone are reviewed. The average follow-up for 22 cases was 7.5 years. The recurrence rate in 19 appendicular tumours treated by curettage, with or without bone grafting, was 52%. Treatment of recurrences, however, resulted in cure of an additional 10 tumours, for an overall success rate of primary and secondary treatment of 89%. Pulmonary metastases occurred in two patients (6.7%) and there was one death attributable to the tumour (3.3%). The authors conclude that the conservative primary treatment is justified even with a 52% recurrence rate, since normal function and appearance are preserved and, further, more aggressive treatment of the recurrent tumour can be performed. They prefer limb-saving resection and occasionally amputation for this more aggressive secondary treatment rather than cryosurgery with its complications, allograft replacement with its uncertainties or supervoltage radiation with its risk of later development of malignant tumours.     

TESTICULAR AND PARATESTICULAR TUMOURS IN CHILDREN: 30 YEARS’ EXPERIENCE

Background : Testicular or paratesticular tumours in children are rare, making it difficult to achieve the best management for these life-threatening diseases. The aim of this study is to review patients during a 30-year period with these tumours and assess clinical aspects to improve management. Methods : The records of 68 patients from 1967 to 1996 were reviewed with respect to age at diagnosis, affected sites, presentation, clinical diagnosis, operation, pathology and prognosis. Results : The most common presentation was a painless scrotal mass (84%). The most common testicular tumour was mature teratoma (n = 27) followed by yolk sac tumour (n = 17). Thirteen patients had paratesticular rhabdomyosarcoma. Two teratocarcinomas, three leydig cell tumours, two sertoli cell tumours, one granulosa cell tumour, one fibroma, one gonadoblastoma, and one secondary tumour from acute myeloid leukaemia were found also. Testis-sparing surgery was performed in 21 of 33 patients with benign tumours (27 teratoma, three leydig cell tumours, two sertoli cell tumours, one fibroma), which caused no recurrence. Only two patients with rhabdomyosarcoma and one with mixed germ cell tumour died of their disease. Conclusion : Recent combined therapy with surgery and chemotherapy against primary testicular and paratesticular tumours has improved prognosis. Testis-sparing surgery should be considered for benign tumours.     

Rupture of papillary renal cell carcinoma

OBJECTIVE: Typical signs of papillary renal cell carcinoma (PRCC) are extensive necroses of the tumorous mass, which can modify the clinical appearance of PRCC. These necroses can imitate cysts on radiological examinations (ultrasonography and CT). The tumours are fragile and vulnerable to spontaneous rupture or rupture following minimal trauma (i.e. they act as a locus minoris resistentiae). MATERIAL AND METHODS: A total of 650 patients with a total of 671 renal tumours were surgically treated at our hospital between January 1991 and December 2003. RESULTS: In 16 cases bilateral tumours were found (in all cases RCC) and in five cases two types of tumour were identified in one kidney [all were a combination of conventional RCC (CRCC) and PRCC]. Altogether, 621 tumours (92.5%) were diagnosed as RCCs. Of these, CRCC was found in 563 cases (90.7%), PRCC in 36 (5.8%), chromophobe RCC in 14 (2.3%) and unclassified RCC in 7 (1.1%). All cases of ruptured PRCC were included in our study. Interestingly, only PRCCs ruptured in this series. Rupture was described in three cases of PRCC (8.3%): it was spontaneous in two cases and resulted from a traffic accident in the third. CONCLUSIONS: The extensive necrosis regularly found in PRCC can cause rupture of the tumour followed by retroperitoneal bleeding. Rupture affected <10% of our cases of PRCC. CT findings are usually not characteristic and can mimic a simple haematoma of unknown origin. Similarly, the perioperative finding is unclear in most cases. The final correct diagnosis of the renal tumour is frequently established only by the pathologist.     

Impalpable testis cancer

OBJECTIVE: To assess the significance of ultrasonographically detected hypoechoic lesions of the testis when the clinical examination is normal, and to highlight the management difficulties thereafter. PATIENTS AND METHODS: Over a 2-year period four patients underwent radical orchidectomy where the sole indication for surgery was a hypoechoic lesion detected on ultrasonography (US). The indications for US were persistent scrotal discomfort in two men, contralateral orchitis, and the follow-up of testicular microlithiasis. The lesions were 4-11 mm in size and one man had several. None of the lesions were palpable; the tumour markers were normal in all patients. RESULTS: Three of the testes contained seminoma; in one there were two foci of seminoma and in all intratubular germ cell neoplasia was also identified. The remaining case was a Leydig-cell tumour. All tumours were staged as pT1 after radical inguinal orchidectomy. CONCLUSION: Impalpable lesions of the testis are likely to be malignant if they are hypoechoic on US and should be considered as seminoma until proved otherwise. The management thereafter is not straightforward, but must ensure an adequate histological diagnosis if the US appearances do not resolve.     

MULTIPLE BILATERAL ANGIOLIPOMAS OF THE BREAST: A CASE REPORT

Angiolipoma, a benign mixed connective tissue tumour which is uncommon in the breast, may be confused clinically, radiologically and pathologically with malignant lesions. An unusual case of multiple, bilateral angiolipomas appearing synchronously and metachronously In the breasts of a 75 year old woman is presented. The apparent recurrent nature of these tumours is considered to result from a change in multiple, pre-existing but previously impalpable tumours in both breasts.     

Management of incidental impalpable intratesticular masses of < or = 5 mm in diameter

OBJECTIVE: To gain more insight into the histology of small incidental intratesticular lesions and evaluate the need for surgical management, as exploratory surgery is the only way to exclude malignancy in testicular tumours. PATIENTS AND METHODS: Between September 2000 and April 2005, incidental intratesticular masses of < or = 5 mm in diameter were found in 20 men undergoing scrotal ultrasonography for reasons other than suspected testicular tumour. After staging, an organ-sparing approach including frozen-section analysis was used to obtain histological data. RESULTS: The mean diameter of the detected tumour masses was 3.5 mm, and the mean (range) age of the patients was 36.4 (26-58) years. Four men (20%) had orchidectomy because the tumours were found to be malignant; the resected specimens yielded multifocal testicular intraepithelial neoplasia (TIN) in all patients and additional seminomatous tumour cells elsewhere in the testis in one. Frozen-section results were false-negative in one patient and he had orchidectomy after having established the definitive histological diagnosis. The 16 patients with benign lesions were correctly diagnosed and their testicles were not removed. CONCLUSIONS: Advanced and innovative ultrasonography technology allows the detection of increasingly small testicular masses. In the present series, most incidental intratesticular lesions were benign. In patients with malignant lesions, multifocal TIN and/or distant seminomatous foci were present despite the tumour being small. Therefore, it is essential to perform exploratory surgery as it is the only way to obtain accurate histological findings, thus providing oncological efficacy and precluding removal of a testicle bearing a benign lesion.     

小儿腹股沟不可触及睾丸的隐睾症诊治

目的:总结腹股沟不可触及睾丸的小儿隐睾症诊治经验。方法:回顾性分析收治腹股沟不能触及睾丸的隐睾患儿36例临床诊治资料。分析腹腔镜手术指征,腹股沟探查指征,术前超声检查的作用和术式的选择。结果:腹股沟不能触及的隐睾共36例(41侧),占总数的10.0%(36/361),经腹腔镜和腹股沟探查确定睾丸缺如18例(侧),腹内型隐睾16例(21侧),阴囊内睾丸残余2例(侧)。将腹腔镜下所见分4型,I型9例(侧),II型9例(侧)(其中IA型7例,IB型2例),III型11例(13侧),IV型7例(10侧)[其中IVA型5例(7侧),IVB型2例(3侧)]。分别采用经腹股沟睾丸下降固定,腹腔镜辅助睾丸下降固定术,分期Fowler-Stephen术。术前超声结果阳性诊断率为75%(27/36),睾丸缺如患儿对侧睾丸体积明显大于腹内型隐睾及睾丸残余患儿对侧睾丸体积。术后随访睾丸萎缩1例。结论:对于腹股沟未能查到睾丸的小儿隐睾症应行腹腔镜检查,腹腔镜下II型者,无需再行腹股沟探查,I型需探查腹股沟及阴囊。III型和IVB型可经腹股沟或腹腔镜辅助下行睾丸下降固定术,IVA型隐睾需在腹腔镜辅助下行睾丸下降固定或行分期Fowler-Stephen术。术前超声检查对侧睾丸大小有利于判断是否有睾丸缺如。     

Classification of bone tumours.

Primary tumours of bone can be classified conveniently into distinct groups based on the appearance of the tumour cell, or its product, or both. Almost all the groups have benign and malignant counterparts. However, malignant bone tumours usually do not arise from benign tumours. Although the cell of origin in many tumours is unknown, the classification described in this paper refers to well-defined clinicopathologic entities, so that the behaviour of a given tumour can be anticipated. This classification is accepted the world over and provides a "common language" for those who treat patients with bone tumours.     

Prospective study of routine scrotal ultrasonography in urological practice

The value of routine scrotal ultrasonography has been evaluated in a prospective study of 109 men with scrotal symptoms or signs. Ultrasonography had a sensitivity of 100% and specificity of 99% for testicular tumour. Clinically useful information was provided in 53% of patients and 8% might have avoided surgery if the ultrasound report had been heeded. Ultrasonography did not provide any additional information in patients with scrotal pain and an entirely normal scrotum clinically, and in those with epididymal cysts in whom the testis was palpably normal. If these 2 groups had been excluded from routine scrotal ultrasonography there would have been a 25% reduction in the number of examinations without any reduction in diagnostic yield.     

Granular cell tumour of the ulnar nerve in a young adult

Granular cell tumours in peripheral nerve trunks are extremely rare. We report a case of a granular cell tumour of the ulnar nerve just distal to the elbow in a 16-year-old man. The appearance of the intraneural tumour could not be differentiated by magnetic resonance imaging (MRI) from more common nerve tumours. At exploration it was impossible to excise the tumour radically. Microscopic examination showed a clearly benign tumour and no malignant transformation has been found at follow-up after three and a half years.     

Granular cell tumour of the ulnar nerve in a young adult.

Granular cell tumours in peripheral nerve trunks are extremely rare. We report a case of a granular cell tumour of the ulnar nerve just distal to the elbow in a 16-year-old man. The appearance of the intraneural tumour could not be differentiated by magnetic resonance imaging (MRI) from more common nerve tumours. At exploration it was impossible to excise the tumour radically. Microscopic examination showed a clearly benign tumour and no malignant transformation has been found at follow-up after three and a half years.     

Testicular adrenal rest tumours in young adult males with congenital adrenal hyperplasia: prevalence and impact on testicular function

Testicular adrenal rest tumours (TARTs) have been described in patients with congenital adrenal hyperplasia (CAH). The aim of the study was to determine the prevalence of TARTs in patients with CAH, the associated factors and their impact on gonadal function. It is a prospective study concerning six young adult men with CAH, four cases with 21‐hydroxylase deficiency and two cases with 11‐hydroxylase deficiency. All patients were under glucocorticoid therapy. The mean age was 25 years (range: 20–31). All patients underwent a physical examination with testicular palpation, scrotal ultrasonography, a blood sample for serum testosterone, FSH, LH, inhibin B, ?4‐androstenedione and 17‐OH‐progesterone measurements and a semen analysis. Ultrasound revealed TARTs in four patients; three were bilateral. The mean tumour size was 6.3 ml (range: 0.02–14.1). The tumours were palpable in two cases. 17‐OH‐progesterone was <10 ng/ml in all cases. Decreased testosterone level was found in one case. The semen analysis revealed azoospermia in one case and poor semen quality in four patients. TARTs were common and associated with impaired spermatogenesis.