A case of metachronous bilateral testicular tumors with burned-out histology in one side

A 22-year-old man with a history of left radical orchiectomy due to a testicular tumor had bilateral pulmonary tumors. Transbronchial biopsy specimens revealed them to be germ cell tumors. The serum levels of AFP and hCG-beta were elevated. The right testis was free from a palpable mass but showed a small hyperechoic lesion on scrotal ultrasonography. We excised the echogenic focus, which was a whitish nodule under the tunica albuginea. By pathological findings it was diagnosed as a burned-out testicular tumor. This was a case with metachronous bilateral testicular tumors.     

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.     

Retroperitoneal germ cell tumor with testicular calcification indicating tiny testicular origin: consideration of the origin of retroperitoneal germ cell tumors: report of two cases

Two cases of germ cell neoplasm retrospectively considered to have been of testicular origin are reported. Case 1. A 19-year-old male with brain, liver and retroperitoneal tumors was diagnosed with yolk sac tumor by retroperitoneal tumor biopsy. After multidisciplinary treatment, a region of calcification was detected in the left testis on scrotal sonography and left high inguinal orchiectomy was performed. Case 2. A 57-year-old male with neck, lung and retroperitoneal tumors was diagnosed with yolk sac tumor by supraclavicular biopsy. From initial examination, scrotal sonography revealed a small calcified lesion in the right testis. After chemotherapy, high inguinal orchiectomy and retroperitoneal lymphadenectomy were simultaneously performed. Pathologic evaluation of these testicular specimens revealed calcification and a fibrous scar in correspondence with the clinical diagnosis. These changes were considered as scars of the primary testicular tumor due to burned-out tumor or the result of reaction to chemotherapy. Since a primary tumor of testicular origin may exist in the extragonadal germ cell tumor, it is important to examine the intrascrotal contents in detail in the case of so-called extragonadal germ cell tumors with palpably normal testes. In such cases, there are two possible conditions, an occult testicular tumor and a burned-out testicular tumor. We briefly reviewed 42 such cases in the Japanese literature. It appears that there are very few true extragonadal germ cell tumors, and that the possibility of primary testicular origin metastasizing from viable occult testicular tumor or burned-out testicular tumor with spontaneous regression is high in retroperitoneal germ cell tumors.     

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.     

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.     

Color Doppler ultrasonography as a routine clinical examination in male infertility

AIM: We assessed the value of scrotal color Doppler ultrasonography as a routine examination in infertile men. METHODS: Color Doppler ultrasonography was performed in 545 infertile men with a mean age of 35.8 years to detect intrascrotal abnormalities. Findings were compared with those of physical examination. RESULTS: Intrascrotal abnormalities were detected by ultrasonography in 65.3% of patients. Of 374 abnormalities, 58.3% were undetected by physical examination. Left varicocele was found in 313 patients (57.4%); testicular microlithiasis in 30 (5.5%); epididymal cyst in 21 (3.9%); right varicocele in 4 (0.8%); and testicular cysts in 3 (0.6%). One occurrence each (0.2%) was found for testicular tumor, intrascrotal hemangioma, and hydrocele of the spermatic cord. Compared to ultrasonography, sensitivity in detecting left varicocele by physical examination was 58.4%; specificity, 79.3%; accuracy, 67.3%; and positive predictive value, 79.3%. Venous diameters in the pampiniform plexus were 3 mm or more in 61.5% of 130 subclinical left varicoceles. Of 30 patients with testicular microlithiasis, 14 had varicocele, 2 had epididymal cyst,s 3 had a history of mumps orchitis, 1 had retractile testis, and 1 had a history of orchiectomy for contralateral testicular tumor. CONCLUSIONS: The routine Color Doppler ultrasonography is valuable for diagnosing scrotal abnormalities in infertile men, frequently detecting non-palpable lesions.     

A rare diagnosis： testicular dysgenesis with carcinoma in situ detected in a patient with ultrasonic microlithiasis

A rare case is presented where a dysgenetic testis with microinvasive carcinoma in situ （CIS, also known as intratubular germ cell neoplasm of unclassified type [IGCNU] and testicular intraepithelial neoplasia [TIN]） with microinvasion to rete testis and the interstitial tissue was found in a 32-year-old man presenting with mild scrotal pain and ultrasonic testicular microlithiasis. Knowledge of the association of ultrasound and CIS is important to diagnose patients at the stage prior to development of an overt germ cell tumor. The patient had three of four disorders considered symptoms of the testicular dysgenesis syndrome （TDS）： a dysgenetic left testicle with CIS, a mild left-sided cryptorchidism （high positioned scrotal hypotrophic testis） and a slightly reduced semen quality. Therefore, it should be kept in mind that a patient with one TDS symptom may harbour the other, even CIS or testicular cancer. Accordingly, patients with one TDS symptom ought to be examined for the presence of the others, and if more that one is present, extra concern is warranted.     

Ultrasound guided needle localization and microsurgical exploration for incidental nonpalpable testicular tumors

PURPOSE: We describe a technique by which incidental, nonpalpable intratesticular tumors are excised using intraoperative ultrasonography and the operating microscope. MATERIALS AND METHODS: Men with impalpable intratesticular tumors incidentally detected by ultrasonography underwent intraoperative ultrasound guided needle localization and microsurgical exploration of the mass. The testis was delivered through an inguinal incision and placed on ice to minimize warm ischemia. Two rubber shod vascular clamps were placed across the spermatic cord. The tumor was identified by ultrasound and localized with a 30 gauge needle, which was placed adjacent to the tumor. An operating microscope providing 6x to 25x magnification was used to excise the lesion with a 2 to 5 mm. margin. Tissue diagnosis was obtained by frozen section. Multiple random biopsies of the remaining parenchyma were done to confirm absent malignancy. RESULTS: Ultrasound showed incidental, nonpalpable testis tumors in 4 of the 65 men who underwent infertility evaluation and were entered into the microsurgical testis biopsy database between January 1995 and December 2001. All lesions were hypoechoic. Frozen section analysis of the lesions revealed 2 Leydig cell tumors, 1 mass with an inconclusive pathological diagnosis and 1 inflammatory mass. On permanent section the latter 2 lesions were seminoma. The seminomas were 1.6 and 0.9 cm. in the greatest diameter, and the Leydig cell tumors were 0.35 and 0.2 cm., respectively. Random biopsies were positive for seminoma and intratubular germ cell neoplasia in both testes with seminoma. These 2 patients subsequently opted to undergo radical orchiectomy. No residual tumor was detected in either radical orchiectomy specimen. CONCLUSIONS: Intraoperative ultrasound guided needle localization with microsurgical exploration is a safe and effective approach to even small impalpable testicular masses. This technique provides the opportunity to identify and remove benign and malignant lesions, and preserve the testis when the lesion is benign. In cases of a solitary testis or bilateral synchronous lesions the technique allows a potentially testis sparing operation for small malignancies.     

Diagnosis of pediatric varicoceles by physical examination and ultrasonography and measurement of the testicular volume: using the prader orchidometer versus ultrasonography

INTRODUCTION: The differentiation of unilateral versus bilateral varicoceles and testicular volume measurements are important in determining the need for adolescent varicocele surgery and also in following patients after varicocelectomy. The aim of this study was to prospectively compare the findings of physical examination and color Doppler ultrasonography in the diagnosis of pediatric varicoceles and to compare the findings using the Prader orchidometer and scrotal ultrasonography in the measurement of testicular volumes. PATIENTS AND METHODS: This study included 68 boys with varicoceles, ranging in age from 8 to 19 years. Varicoceles were diagnosed using both physical examination and scrotal color Doppler ultrasonography. The testicular volumes of 136 testicles were measured using the Prader orchidometer and scrotal ultrasonography. A difference of more than 10% or 2 ml in each testicular volume was considered significant. RESULTS: The mean age of the boys was 13.5 +/- 2.3 years. On physical examination, a left unilateral varicocele was diagnosed in 46 boys (67.6%). The other 22 boys (32.4%) had bilateral varicoceles. Color Doppler ultrasonography detected bilateral varicoceles in 4 of the 46 boys (8.7%) who were diagnosed by physical examination as having only left unilateral varicoceles (grade 3 in 3 patients and grade 2 in 1 patient). A different of more than 10% or 2 ml in testicular volume using the Prader orchidometer versus scrotal ultrasonography was detected in 3 out of 136 testicles (2.2%). The correlation between ultrasonography and Prader orchidometer results in the measurement of testicular volumes was statistically highly significantly consistent using the intraclass correlation test (r = 0.997 and p < 0.001 for the left testis; r = 0.998 and p < 0.001 for the right testis). CONCLUSIONS: Although the management of subclinical varicoceles remains controversial, these data show that color Doppler ultrasonography may be necessary in the diagnosis of bilateral varicoceles, especially in boys with high-grade left varicoceles. In contrast, scrotal ultrasonography, if considered the gold standard, did not show superiority over the Prader orchidometer in measuring testicular volumes.     

Ultrasonographic findings of testicular microlithiasis associated with intratubular germ cell neoplasia.

Testicular microlithiasis is an uncommon condition in which calcified concretions fill the lumina of seminiferous tubules. We report the case of a twenty-three-year-old white man with a metastatic germ cell tumor and normal findings on testicular physical examination, but abnormal ultrasonography of the right testis. Orchiectomy revealed intratubular germ cell neoplasia with testicular microlithiasis. Multiple circular echogenic foci on ultrasound correlated with the histologic finding of testicular microlithiasis. Further studies are indicated for assessing ultrasonography as an adjunct for screening the population at risk for intratubular germ cell neoplasia.     

Sonography in the early detection of non-palpable second testicular tumors: a prospective study

As part of the tumor aftercare service afforded by our policlinic, 91 patients were examined one to six times in 18 months following radical orchiectomy for testicular germ cell tumors. The period of observation averaged 35 months (3-147) after the contralateral removal of the testicle. In addition to the usual routine checks, sonography of the residual testicle also formed part of the established followup protocol. Among these patients sonography identified in residual testicles 3 testicular tumors (3.3%) which had escaped detection on palpation. The existence of these second tumors was demonstrated 3, 25 and 38 months following contralateral orchiectomy. In all instances the second lesion differed from the first tumor in histology. In another patient a plum-sized malignancy was revealed within a large concurrent hydrocele by scrotal sonography carried out 18 months following preceding contralateral orchiectomy. Thus, our group of patients gave an incidence of 4.4% for second primary testicular tumors, a poor known incidence rate. Such malignancies can be spotted early by ultrasound, they are genetically obscure just as the increasing morbidity of the unilateral disease. These results urgently suggest that after semicastration for testicular germ cell tumor the residual testicles should be regularly scanned by ultrasonography at four-month intervals. Retrograde sonography has been shown to detect even those small occult testicular tumors which pass unnoticed until metastasizing.     

A rare simultaneous presentation of testicular mixed germ cell tumor with a contralateral testis torsion

We report a rare case of a 27-year-old man presenting with an acute scrotum with simultaneous occurrence of testicular tumor and contralateral torsion. Preoperative imaging demonstrated the testicular missed torsion, yet findings were equivocal with regard to the testicular tumor. On scrotal exploration the left testis was found to be ischemic due to threefold rotation. The right testis was not identifiable, being composed of numerous necrotic lesions. Frozen section suggested malignancy, hence high right orchiectomy was performed. Histologic examination of the right testis showed mixed germ cell tumor, containing all the subtypes. To our knowledge no similar case has been reported.     

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.     

Measurement of testicular volume by ultrasonography

To measure testicular volume accurately, an ultrasonographic method was developed and the results obtained from this compared with those obtained by conventional measurements, namely (1) comparison with testis models, (2) an orchidometer, and (3) measurement of testicular volume by calipers through the scrotal skin. Data from these methods were compared with the actual volume measured at operation by slide calipers placed directly on the testis. The volume obtained by comparison with testis models or with an orchidometer tended to over-estimate the actual volume. The volume measured by slide calipers on scrotal skin was also found to be incorrect. On the other hand, the volume measured by ultrasonography proved to be closer to, and to correlate well with, the actual volume, and was considered to be the best method.     

Testicular tumors: wide spectrum in our short casuistics

Testicular tumors occur in 0.5 to 2 per 100,000 children. They are 1-2% of all solid tumors before puberty. The clinical history, testicular and abdominal ultrasonography, alpha-fetoprotein and human chorionic gonadotropin, estrogens and androgen levels, FSH and LH determine the diagnosis. The pathology determines the specific cell. We report seven cases, three germ cell tumors: a Yolk sac tumor in a child of 18 months and two mature teratomas in children between 2 and 11 years presenting as a painless testicular mass without other symptoms. Three tumors estrumales: one derived from Leydig cells and two of the granulosa cells, a palpable testicular mass was added precocious puberty in stage II-III of Tanner in the first, second gynecomastia in Tanner stage III and the third only with testicular mass. The seventh case, Lipoma para-testicular mass palpable. The treatment was radical orchiectomy in five cases. Testis-sparing surgery in Leydig cell tumor and resection of the paratesticular mass was performed through scrotal. The Yolk sac tumor requiring chemotherapy with good outcome. Retroperitoneal lymph node dissection is not recommended in prepubertal. Historically prepubertal testicular tumors have been treated in adults. Recent testicular preservation algorithms optimize and minimize the morbidity of adjuvant therapies. Many are benign and can be treated with preservation of the testis. Localized malignant tumors can be treated by orchiectomy.     

IS ROUTINE SCROTAL ULTRASOUND ADVANTAGEOUS IN INFERTILE MEN?

PURPOSE: We determine the value of routine scrotal ultrasonography in the evaluation of male infertility. MATERIALS AND METHODS: Scrotal color Doppler ultrasonography reports of 1,372 infertile men were reviewed to assess the prevalence of scrotal abnormalities and compared to clinical findings. RESULTS: The prevalence of scrotal abnormalities was 38%. Testicular tumor was found in 0.5%, varicocele in 29.7%, testicular cyst in 0.7%, testicular microlithiasis in 0.9%, epididymal cyst in 7.6% and hydrocele in 3.2% of the cases. Overall, 67% of sonography findings were not evident on palpation, and only 1 of 7 testicular tumors was suspected. Of the varicoceles 60% were not found on physical examination. The rate of testicular tumors (1/200) was higher than that reported for the general European population (1/20,000). CONCLUSIONS: Routine scrotal ultrasound provides valuable information in the diagnostic evaluation of infertile men and substantially more pathological conditions are detected compared to clinical palpation. The high prevalence of testicular malignancies underlines the clinical relevance of routine scrotal ultrasonography in infertile men.     

Mixed germ cell tumor after bilateral orchidopexy in persistent Müllerian duct syndrome with transverse testicular ectopia

The persistent müllerian duct syndrome is characterized by the retention of müllerian derivatives (fallopian tubes, uterus) in patients otherwise normally virilized, usually with cryptorchidism or an inguinal hernia. Very rarely, this syndrome is associated with transverse testicular ectopia, which designates the condition when both testes descend through the same inguinal canal into the same scrotal sac. We report on a patient with both conditions, who had T1N2M0 scrotal mixed germ cell tumor of the testis (teratoma and embryonal carcinoma), 18 years after bilateral orchidopexy. The literature concerning this uncommon association is reviewed.     

Transverse testicular ectopia with scrotal hypospadias but without inguinal hernia – Case report of a rare association

Transverse testicular ectopia is an extremely rare anomaly, in which both the testis migrate towards the same hemiscrotum through the same inguinal canal. It is usually associated with other abnormalities such as persistent Mullerian duct syndrome, true hermaphroditism, inguinal hernia, pseudohermaphroditism, and scrotal anomalies; the association with inguinal hernia being the commonest. We, here, report a case of transverse testicular ectopia in a 12 years old boy having the ectopic testis in contralateral hemiscrotum without any inguinal hernia but having scrotal hypospadias with severe chordee. The diagnosis was made on clinical examination and confirmed on ultrasonography. Trans-septal orchiopexy was done for ectopic testis and hypospadias and chordee were managed by staged repair.     

P53 and Fas are sequential mechanisms of testicular germ cell apoptosis.

Testicular germ cell apoptosis in the cryptorchid testis is induced by abdominal heat stress. p53-dependent apoptosis appears responsible for the initial phase of germ cell loss in experimental cryptorchidism based on a 3-day delay of apoptosis in p53-/- mice. However, the mechanisms underlying the subsequent p53-independent apoptosis have not been identified. Although studies have suggested that Fas plays a role in testicular germ cell apoptosis, no direct evidence has been shown. To test the hypothesis that Fas is involved in testicular germ cell apoptosis and is responsible for the p53-independent phase of apoptosis in the cryptorchid testis, p53-/-, lpr/lpr (a spontaneous mutation in the Fas gene, which causes autoimmune disease) double-mutant mice were generated and unilateral cryptorchidism was induced in these mice. It was found that testicular weight reduction and germ cell apoptosis were delayed by an additional 3 days, and the Fas production increased in the time frame of p53-independent apoptosis in the experimental cryptorchid testis of wild-type mice. These results suggest that Fas is involved in testicular germ cell apoptosis, and that Fas-dependent apoptosis is responsible for the p53-independent phase of germ cell apoptosis in the cryptorchid testis. The cascade of testicular germ cell apoptosis in response to heat stress implies the existence of sequential quality control mechanisms in spermatogenesis.     

Fine needle aspiration vs. mTESE in non-obstructive azoospermia

This study was carried out on 100 patients with non-obstructive azoospermia (NOA) to compare between results and complications of fine needle aspiration (FNA) vs. microdissection testicular sperm extraction (mTESE) sperm retrieval. They underwent history taking, clinical examination, semen analysis, serum follicle stimulating hormone estimation and scrotal Duplex. One testis was subjected to FNA screening whereas the other testis was subjected to mTESE and histopathology. Follow-up was by ultrasonography at 1, 3 and 6 months. The overall sperm retrieval rate was 54% by mTESE and 10% by FNA. Spermatozoa were retrieved by mTESE from all cases with hypospermatogenesis, severe hypospermatogenesis, 30% of Sertoli cell only (SCO), 16.7% of germ cell arrest and in 28.6% of tubular hyalinization. Sperms were retrieved by FNA in 33.3% of hypospermatogenesis, 9% in severe hypospermatogenesis, 5% in SCO, 16.7% in germ cell arrest, while no sperms were retrieved in the tubular hyalinization group. The total complication rate following mTESE was 10% in the early phase and none in the long-term follow-up compared to 24% of FNA side. It is concluded that mTESE is superior to FNA as regards sperm retrieval rate and lower incidence of complications in NOA patients.