Testicular mass in 40M • Xray of the Week 2016 • Week #26
This 40 year old male presented with a large tender right testicular mass and a left neck supraclavicular mass. What is the diagnosis?
Above top left image: Ultrasound demonstrating a large right testicular heterogeneous mass.
Lower left image: Ultrasound demonstrating testicular microlithiasis in the otherwise normal left testis.
Top right image: CT demonstrating left para-aortic lymphadenopathy.
Lower right image: Ultrasound demonstrating a large biopsy -proven metastatic node in the left side of neck.
Testicular seminoma, a type of germ cell tumor, is the most common testicular neoplasm, accounting for nearly half of all cases. Undescended testis has a 10 - 40 fold increase in the risk for seminoma, and there is also increased risk in the contralateral testis, even if it is within the scrotum. Presentation with distant disease is rare as most cases present with a painless mass confined to the testis (stage 1). Ultrasound findings are a hypoechoic intratesticular mass, usually confined within the tunica albuginea. Retroperitoneal lymphadenopathy (stage 2) is seen in 15% at presentation, while distant metastatic disease (stage 3) is only present in about 5% of patients. Treatment is orchiectomy, radiation therapy of the nodal disease, and chemotherapy. Prognosis is excellent with a greater than 90% five year survival.
Testicular microlithiasis is present in about 50% of men with a germ cell tumor. (1,2) However, the association with testicular microlithiasis is very controversial. Some authorities recommend screening ultrasound on all patients with the condition. (1) Recent articles concluded that screening is necessary in only a select high risk population with the following characteristics: a personal history of germ cell tumor, first degree relative with testicular cancer, undescended or maldescended testis, infertility, or testicular atrophy. They state that patients with testicular microlithiasis and no risk factors should be screened the as the rest of the population, with monthly testicular self exam.(2,3)
The 2 slides above are from a talk by Andrew Trout, MD of Cincinnati Children’s Hospital, the lead investigator of a multi-center retrospective study of 38,000 patients with testicular microlithiasis. These were presented at The International Pediatric Radiology Congress on May 17, 2016 in Chicago. The study showed about a 3% rate of testicular microlithiasis in the general population and a significant, strong association with testicular neoplasia. (4) The odds ratio are as follows:
Malignant germ cell tumor: 22
Benign germ cell tumor: 11
Stromal tumor: 6
The study is still in progress and there are no specific recommendations for screening.
1. Richenberg J, Belfield J, Ramchandani P et-al. Testicular microlithiasis imaging and follow-up: guidelines of the ESUR scrotal imaging subcommittee. Eur Radiol. 2015;25 (2): 323-30.
2. Shanmugasundaram R, Singh JC, Kekre NS. Testicular microlithiasis: Is there an agreed protocol?. Indian J Urol. 2007;23 (3): 234-9.
3. Winter T, Kim B, et-al. Testicular Microlithiasis: What Should You Recommend? American Journal of Roentgenology. AJR Vol. 206: Issue. 6: Pages. 1164-1169
4. Trout A, et-al. Large multicenter study of the association between testicular microlithiasis and neoplasia in a pediatric population. Abstract presented at The International Pediatric Radiology Congress on May 17, 2016.
Tweets from Andrew Trout, MD acknowledging the accuracy of this post:
Kevin Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Member of Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field.
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