Radiology Pathology Testicular Pathology Before You Begin This
Radiology - Pathology Testicular Pathology
Before You Begin This module is intended primarily for pre-clinical students learning or reviewing pathophysiology. Please note that this series will focus on how pathology presents in imaging studies. It assumes familiarity with fundamental anatomy. If you need to learn or review this core concept, please visit the “Anatomy” section of our website. If material is repeated from another module, it will be outlined as this text is so that you are aware
Based on Publication from Radiographics
Radiographic appearance of the normal testicle Testes initially form in the lumbar region of the abdomen and successfully migrate to the scrotum 97% of the time for fullterm male infants. Most testis that are undescended at birth (cryptorchidism) move to the scrotum at 3 months The testicles are superficial organs and are best initially imaged with high frequency ultrasound (no radiation) Testicular echotexture should be homogeneous Doppler flow can be assessed/confirmed within the testicular parenchyma
Normal Testicle Homogeneous testicular echotexture with normal Doppler flow
Testicular Pathology A. Non neoplastic (palpable lump that is not malignant) B. Neoplastic (i. e. palpable lump that is malignant) C. Ischemia/torsion D. Infectious/inflammatory D. Post traumatic
Ultrasound work up for a scrotal lump 1. Intratesticular or extra testicular? Extratesticular lesions are more commonly benign Intratesticular lesions are more commonly malignant 2. Solid or cystic (see “intro to rad path” module for review) Solid intratesticular lesions are worrisome 3. Single or multiple? If multiple, think mets/lymphoma (intro to rad path)
Scrotal Lump * US image shows an anechoic extratesticular cyst (calipers) which is separate from the testicle (*). This was an epididymal cyst/spermatocele
Testicular Pathology Benign Color Doppler US image shows an anechoic intratesticular cyst (arrow) with no internal vascularity. This is a testicular cyst (benign).
Testicular Pathology Malignant a b * Seminoma in a 33 -year-old man. (a) Gray-scale US image shows a homogeneous lobular intratesticular mass (arrow). (b) Color Doppler US image shows internal blood flow in the mass (arrow). (c) Photograph of the gross specimen shows a lobular homogeneous mass (arrow). (d) Photomicrograph (original magnification, × 400; hematoxylin-eosin [H-E] stain) of the specimen shows fried egg–like neoplastic cells (arrows) c d
Testicular Tumors Solid intratesticular mass with internal vascularity represents a testicular tumor until proven otherwise Can be divided into seminomatous and nonseminomatous tumors Remember that the testes originated in the perilumbar region. Lymphatic drainage follows venous drainage such that testicular malignancies will drain into the para-aortic nodes
Testicular Metastases—Path of Spread * Axial contrast-enhanced computed tomographic (CT) image shows a large (>5 -cm) retroperitoneal mass (arrow) surrounding the aorta (*) at the level of the kidneys
Testicular Tumors Germ Cell Tumors 1. Seminoma 2. Embryonal carcinoma 3. Yolk sac tumor 4. Teratoma 5. Mixed germ cell tumor Sex cord-stromal tumors 1. Leydig cell tumor 2. Sertoli cell tumor 3. Granulosa cell tumor 4. Thecoma-fibroma Miscellaneous tumors: 1. Lymphoma (especially if multiple) 2. Leukemia (especially if multiple) 3. Sarcoma
a c Mixed NSGCT in a 57 -year-old man. (a) Gray-scale US image shows a partially cystic and partially solid intratesticular mass (arrow). (b) Photograph of the gross pathologic specimen shows cystic spaces within the mass (arrow). (c)Photomicrograph (original magnification, × 200; H-E stain) of the specimen shows yolk sac and embryonal cell carcinoma elements (arrow). b
Testicular Cancer Fake Outs: Blood and Pus Intratesticular abscess mimicking a tumor. Color Doppler US image shows a 2 -cm intratesticular mass with internal echoes, no definite internal blood flow, and perilesional hyperemia (solid arrow). A complex hydrocele is also visible (dashed arrow). The intratesticular lesion did not resolve after intravenous antibiotic therapy, and the patient underwent orchiectomy. Photomicrograph (original magnification, × 100; H-E stain) of the specimen shows purulent debris.
Acute pain: Think torsion or infection
Which testicle is abnormal? 18 -year-old male, who was awoken from sleep with severe left testicular pain. US demonstrates no flow in the left testicle. Notice the normal flow in the right testicle. The urologist was able to detorse the testicle and restore flow to the testicle which “pinked up” in the operating room.
Which side is abnormal? * 40 year old with right sided pain and epididymitis. Note the enlarged and hypervascular epididymal head (*) and testicle (arrow)
Epididymo-orchitis • Epididymitis is inflammation of the epididymis and may extend into the testis like this case • Infectious process that usually originates in the bladder or prostate gland, extends through the lymphatics of the spermatic cord to the epididymis and may reach the testis • Presents as mild tenderness to a severe febrile process with unilateral pain • The involved epididymis is usually enlarged and hypervascular
Scrotal Trauma—Which side is abnormal?
Testicular Rupture 45 year old third base coach (not wearing his cup) hit by a foul ball There is no Doppler flow to the shattered left testicle (compare this with the normal flow to the right testicle). Also the testicular parenchyma is amorphous (i. e. it is difficult to draw a line around the border of the testicle).
Testicular Pathology Summary Remember the ultrasound work up: 1. Intra or extra testicular? 2. Solid or cystic? 3. Single or multiple? 4. Is there flow? Solid intratesticular mass represents tumor until proven otherwise
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