Testicular Seminoma and Its Mimics: From the Radiologic Pathology Archives

Imaging of scrotal masses

Testicular cancer is responsible for approximately 0.1% of all cancer deaths in the USA, and seminoma is the most common type of testicular tumor. Ultrasonography is the primary imaging modality for accessing testicular and extratesticular lesions, while magnetic resonance imaging can be used for problem solving in lesion characterization in certain cases. CT imaging is usually performed for retroperitoneal staging of testicular cancer metastasis and follow-up after treatment. Extratesticular masses are common, yet rarely malignant. Imaging plays an important role in primary diagnosis of testicular cancer and differentiating it from common non-neoplastic findings. The purpose of this article is to review various imaging findings in testicular and extratesticular masses.

Splenogonadal fusion: A rare case report and literature review

Splenogonadal fusion is a rare benign congenital anomaly with few cases described in the literature. It is 16 times more common in males than in females. A 22 year-old healthy male with cryptorchidism presented with preoperative imaging strongly suggestive of malignancy. Histopathology after left orchiectomy showed mixed splenic and testicular tissue with no sign of malignancy. Splenogonadal fusion is rarely diagnosed preoperatively. It should be included in differential diagnoses in patients presenting with a testicular or abdominal mass. Greater recognition of this rare anomaly may facilitate testis sparing surgery in future cases.

Overview of ultrasound applications for assessing scrotal disorders

The scrotum may be affected by a plethora of different disorders such as infections, vasculopathies, trauma, and manifestations of primary and secondary malignant masses. In addition to the patient's medical history and clinical examination, ultrasound represents the imaging modality of choice to assess scrotal disorders. Time-consuming contrast-enhanced ultrasound and elastography can provide further information to distinguish between benign and malignant testicular mass lesions. The following invited Special Communication gives a comprehensive overview of differential diagnoses of the scrotum and their corresponding sonomorphologic correlates based on representative cases of the Interdisciplinary Ultrasound Center of the University Hospital Munich.

Characterization and distribution of sialic acids in human testicular seminoma

Aberrant content of sialic acids (Sias) has been observed in various human cancer types in different organs. Sias have been implicated in cancerous transformation, invasiveness and metastasis, and in the escaping of cancer cells from immune surveillance. Indeed, Sias are commonly regarded as important biomarkers to distinguish cancer cells from their healthy counterparts. However, scarce and not exhaustive investigations have been performed on Sia content in testicular cancers and, in particular, in seminoma, one of the most common malignant testicular tumors. Hence, the aim of this study was to investigate the content and distribution of Sias with different glycosidic linkage, namely α2,3 and α2,6 galactose- or N-acetyl-galactosamine-linked Sias and polymeric Sia (polySia), in the germinal and stromal components of human testes affected by seminoma compared to normal testicular tissue. Structural changes in seminoma tissue were examined using hematoxylin-eosin staining. α2,3 and α2,6 linked Sias were evaluated by lectin histochemistry (Maackia amurensis agglutinin (MAA) and Sambucus nigra agglutinin (SNA)), while confocal immunofluorescence was used for polySia detection. Histopathological findings in seminoma tissue included loss of seminiferous tubules replaced by clusters of uniform polygonal cells with a clear cytoplasm, bundles of fibrotic tissue, numerous microvessels and some atrophic tubules. The content of α2,3 and α2,6 linked Sias was lost in almost all seminoma components respect to normal tissue, with the exception of microvessels in which it was higher. On the contrary, polySia level was increased in all the seminoma components compared to normal testicular tissue. Our findings suggest that an aberrant content of different Sias might have important and differential roles in seminoma development and progression. In particular, polySia might be implicated in seminoma progression by promoting cancer invasiveness and regulating the cross-talk between cancer cells, reactive stroma and vessels. Thus, the possibility that polySia might represent an important biomarker for seminoma deserves further investigation.

The role of diagnostic imaging in the primary testicular cancer: initial staging, response assessment and surveillance

Testicular cancers are a group of uncommon malignancies that account for less than 1% of new cancer cases per year in the United States and globally. The disease typically affects men between the ages of 20-44, and the overwhelming majority of tumors are germ cell in origin. Most cases of testicular cancer are organ confined at diagnosis and have a good overall prognosis. Testicular cancers are staged by the tumor, node, metastasis, serum markers (TNMS) classification set forth by the American Joint Commission on Cancer staging. Diagnostic imaging plays a crucial role in initial staging, specifically in assessing the primary tumor prior to orchiectomy and evaluating for regional and/or distant metastasis. Multimodality imaging is used for initial staging, with ultrasound and computed tomography (CT) most commonly utilized. Diagnostic imaging is also important in evaluating response in patients who initially present with metastatic disease as well as in patients who are undergoing surveillance. Typically, CT is used for response assessment and surveillance, with magnetic resonance imaging (MRI) and positron emission tomography (PET) serving as adjunct modalities. This article reviews the role of various diagnostic imaging modalities and how they are employed in the diagnosis, staging, response assessment and surveillance of primary testicular cancer.

Classic Testicular Seminoma in Men Aged 50 Years or Over: A Case Report and Review of the Literature

Testicular cancer is the most frequent solid tumor detected in young adult men. Germ cell tumors (GCTs), particularly seminomas, are the most common type of testicular neoplasms seen in that age population. Most publications have reported decreasing incidence of GCTs in patients above forty years of age. Since the biologic activity of seminomas appears similar across ages, recommended management of senior adults involves a multimodal therapy of radical inguinal orchiectomy with radiation or cytotoxic treatment as needed. Attenuating chemotherapy dosages are critical to ensure better tolerability of associated adverse events. Here we report a case series of 2 men older than fifty years of age with metastatic testicular seminoma. We aim to emphasize a rare clinical entity encountered in the senior adult population.

Changes in the telocyte/CD34+ stromal cell and α-SMA+ myoid cell networks in human testicular seminoma

Telocytes (TCs), also known as CD34+ stromal/interstitial cells, have recently been identified within the connective tissue of a variety of organs including the normal human testis. Testicular TCs appear to constitute a widespread reticular network distributed either in the peritubular or in the intertubular stromal spaces where they have been suggested to play different roles, such as participation to testis morphogenesis, postnatal preservation of the normal tissue/organ three-dimensional structure, and regulation of spermatogenesis and androgen hormone secretion and release. Although increasing evidence indicates that TCs may be involved in the pathophysiology of various diseases, no study has yet reported possible changes in these cells within the stromal compartment of seminoma, one of the most frequent malignant testicular cancers in humans. Therefore, here we carried out the first investigation of the presence and tissue distribution of TCs/CD34+ stromal cells in human testicular seminoma in comparison with normal human testis using either CD34 immunohistochemistry or CD34/CD31 and CD34/α-smooth muscle actin (α-SMA) double immunofluorescence analyses. In seminoma tissue sections, we observed an overall loss of TCs (CD34+/CD31- stromal cells) accompanying a severe degeneration of the normal architecture of seminiferous tubules and stromal tissue associated with dense cellularity increase and presence of interstitial fibrosis. Noteworthy, in the seminoma tissue the disappearance of TCs was paralleled by an expansion of α-SMA+ myoid cells. Moreover, the CD34+/CD31+ blood vessel network was greatly expanded, while steroidogenic Leydig cells were undetectable in seminoma specimens. Since TCs are emerging as important regulators of tissue and organ homeostasis, collectively the present findings indicate that the possible pathophysiologic implications of the loss of TCs in human testicular seminoma should not be further overlooked.

Testicular Cancer at the University of Port Harcourt Teaching Hospital: A 10-year Retrospective Review

BACKGROUND

Testicular cancers are rare malignancies. They are however very common in males aged 15-40 years. Reports of increasing incidence of testicular cancer in western countries have been noted. Despite the increasing incidence, mortality has remained low in these countries. There are few publications on the management of testicular tumors in Nigeria.

AIM

The aim of this study was to determine the hospital prevalence and highlight our experience in the management of patients with testicular cancer.

MATERIALS AND METHODS

This was a 10-year retrospective study on patients diagnosed with histologically confirmed testicular cancer from January 2009 to December 2018. The case records were retrieved. Data obtained included biodata, clinical presentation, investigations, treatment received and outcomes. Data analysis was carried out using SPSS version 20.0.

RESULTS

Eleven patients with testicular cancer were managed during the study period, constituting 0.01% of new cases seen in the hospital. Peak age was 20-29 years (54.55%), with a mean age of 29.27 ± 9.51yrs. The most common presentation was painless scrotal swelling, observed in nine (81.8%) patients. Nine (81.8%) patients presented six months or more after onset of symptoms with advanced disease. Distant metastasis was seen in two (18.2%) patients. Right sided disease was found in seven (63.6%) and left sided disease in four (36.4%). All had radical inguinal orchidectomy. The most common histological diagnosis was seminoma in 8 (72.7%) patients. All the subjects were offered four courses of chemotherapy with bleomycin, etoposide and cisplatin. However, only four (36.4%) completed the chemotherapy. A statistically significant association was observed between the duration of symptoms and the disease stage (P = 0.003), and between number of chemotherapy sessions and survival (P = 0.02).

CONCLUSION

Testicular cancer was an uncommon condition in the catchment area of the University of Port Harcourt Teaching Hospital, affecting relatively young men. The commonest presenting complaint was painless scrotal swelling. Most patients presented with Stage II disease, with seminoma being the commonest histopathology. All had surgical treatment; adjuvant chemotherapy improved 5-year survival. Public education is necessary to surmount sociocultural barriers to effective management of testicular tumors in our environment.

Testicular epidermoid cysts: a reevaluation

Background

Testicular epidermoid cysts (TECs) are rare benign testicular neoplasms. As TECs are rarely associated with germ cell tumours (GCTs), the understanding of biological behaviour and clinical management of TEC is unresolved.

Methods

We retrospectively searched the files of patients treated for testicular neoplasms and germ cell cancer in the time from 2000 to 2017. Those with TEC were subjected to closer review looking to clinical and histological features, and to results from imaging with ultrasonography (US), contrast enhanced sonography (CEUS) and magnetic resonance imaging (MRI).

Results

Among 589 patients undergoing surgery for testicular tumour, nine simple TECs were identified (1.5, 95% confidence intervals 0.53–2.50%). Median age was 26 years. Imaging revealed sharply demarcated roundish lesions with avascular central areas. Eight patients underwent testis-sparing excision with no recurrence ensuing. One had orchiectomy because of large size of the mass. Histologically, TECs consisted of cornifying squamous cell epithelium and no accompanying germ cell neoplasia in situ. Two additional cases (0.3% of all) required orchiectomy because these TECs were associated with ipsilateral GCT.

Conclusions

TEC is usually a benign lesion that can safely be diagnosed with US, CEUS and MRI due to its roundish shape and its avascular centre. Histologically, this TEC corresponds to the prepubertal-type teratoma unrelated to germ cell neoplasia in situ of the 2016 WHO classification. The other subtype of TEC that is associated with invasive GCT represents a teratoma of postpubertal-type. From a clinical point of view it could be easier to differentiate between a “simple TEC” which is benign (prepubertal type) and a “complex TEC” which is malignant because of its association with invasive GCT.

Diagnostic value of contrast-enhanced ultrasound (CEUS) and comparison with color Doppler ultrasound and magnetic resonance in a case of scrotal trauma

Intratesticular hematoma is one of the most frequent presentations of scrotal trauma. Ultrasound is the first-line imaging modality in the evaluation of scrotal trauma, and its findings are crucial for the choice of treatment. An intratesticular hematoma may represent a diagnostic pitfall for the investigating physician since its appearance may mimic other conditions, such as testicular neoplasms or segmental infarction. Although the gold standard imaging modality for the characterization of a testicular lesion is contrast-enhanced magnetic resonance (MR), MR equipment is not always available in an emergency department. Contrast-enhanced ultrasound (CEUS) may represent a valid and cheaper alternative compared with MR, which may aid the physician in the differential diagnosis. We describe the case of a 19-year-old male with a scrotal trauma following a motorcycle crash. In accordance with the literature, we carried out a contrast-medium whole-body computed tomography for the evaluation of any potential traumatic injury. Because of scrotal swelling and the patient complaining about pain in the right testicle, we performed a scrotal ultrasound, which demonstrated an enlarged right testicle, with an inhomogeneous echostructure due to the presence of a hypoechoic area in the middle and upper portion of the testicle. Color Doppler ultrasound did not show signals of intralesional vascularization. The lesion, although having characteristics compatible with hematoma, must not be diagnosed as testicular neoplasia, segmental infarction, or other mimics. For more information, a CEUS examination was performed. The examination clearly showed the extent of the lesion, the integrity of the testicular capsule, and the absence of internal vascularization; all these findings were regarded as indicators of a testicular hematoma. After the urological examination, the patient was prescribed antibiotic therapy and bed rest. For further confirmation of the CEUS examination, an MR was performed 2 days later, showing a perfect correspondence with the CEUS findings. Our case demonstrates that CEUS is a faster, cheaper, and valid alternative to MR in an emergency setting, as in testicular trauma, in which the hematoma may mimic conditions (neoplasm) that require a different treatment.

Testis-sparing surgery for testicular masses: current perspectives

INTRODUCTION

Males who present with a palpable testis nodule are likely to have malignant germ cell tumor in >90% of cases. Therefore radical orchiectomy remains the standard of care for intratesticular tumors. However, due to the recent developments of high-frequency probes in ultrasonography, the incidence of detecting a small non-palpable testis tumor is higher and higher. These lesions are thought to be benign in more than 60-80% of cases, thus a radical orchiectomy should be considered an overtreatment. In addition to that, radical orchiectomy might cause infertility, psychological issues and endocrine disorders, hence an organ-sparing procedure in such cases should be pursued.

EVIDENCE ACQUISITION

Only fourteen reliable retrospective studies met the inclusion criteria. No prospective randomized trials have appeared in Medline database.

EVIDENCE SYNTHESIS

This review of the current literature has confirmed the safety and efficacy of testicular-sparing surgery in selected patients: 1) monorchid patients; 2) bilateral testis masses; 3) normal patients with a small, non-palpable masses detected with US, as long as the dimension of the lesion is up to 3 cm and not greater that 30% of the total volume of the organ.

CONCLUSIONS

According to the literature, testis sparing surgery is a safe and feasible procedure for patients presenting a benign small testis mass. The enthusiasm found in the literature should however be tempered as the small number of patients reported in the studies coupled with the absence of a prospective trial represent important limits that need to be overtaken. Therefore more robust and well-designed studies are needed.

Scrotal Ultrasound

Ultrasound is the imaging modality of choice to evaluate the scrotum because of its high resolution, Doppler capabilities, availability, and lack of ionizing radiation. Acute urologic emergencies diagnosed with ultrasound include testicular torsion, testicular rupture, and Fournier gangrene. The radiologist's knowledge of sonographic features of vascular, infectious, traumatic, and benign and malignant processes that occur in the scrotum coupled with the patient's presenting symptoms, age, and physical examination allows for the correct diagnosis of a wide spectrum of scrotal pathology.

Ambiguous presentation of an intra-abdominal testicular seminoma in a 40-year-old man: a case report

Background

Cryptorchidism is the most common congenital malformation of the male genitourinary tract. The cryptorchid testis is most often located in the inguinal canal; however, intra-abdominal locations are not rare. The risk of malignancy in an undescended testis is 10% with the highest risk in an intra-abdominal testis.

Case presentation

Here we describe a case of a 40-year-old fertile man of Fulbe origin who presented with a non-tender lower abdominal mass of 2 months’ duration. A scrotal examination revealed just one testis in the right scrotum, with the contralateral scrotum and inguinal canal being empty. An exploratory laparotomy followed by tumor excision and histopathology revealed a testicular seminoma.

Conclusion

This case report highlights the need for routine scrotal examination in all men presenting with an abdominal mass so as to rule out the possibility of an intra-abdominal seminoma.