Testicular microlithiasis in 2 children with bilateral cryptorchidism

Prevalence of small testicular hyperechogenic foci in subgroups of 382 non-vasectomized, azoospermic men: a retrospective cohort study

Testicular hyperechogenic foci (THF) are associated with Klinefelter's syndrome, cryptorchidism, infertility, and testicular germ cell neoplasia. The aims of the study were to evaluate THF in relation to etiology of azoospermia and to Sertoli cell dysfunction. The structures inside the scrotum of consecutive non‐vasectomized, azoospermic were examined by ultrasonography, and hormone (FSH, LH, testosterone, and prolactin), and genetic analyses (karyotype, Y microdeletions, and CFTR mutations) were performed. At testicular ultrasonography, patients were graduated into: pronounced THF (>7 THF per transducer field), distributed universally (uTHF) or collected in plaques (pTHF), borderline THF (bTHF; 3–7 THF per transducer field), or no THF (<3 THF per transducer field). Diagnostic testicular biopsy was taken open or with TruCut needle (14G). THF status was sufficiently described in 382 of 449 potential participants, and testicular histology was available in 300 cases. Presence of ultrasonographically detectable THF was compared to presence of testicular microlithiasis (TM) detected histologically. Sertoli cell dysfunction was investigated in a subgroup using a three‐stage immunoperoxidase technique for detection of cytokeratin‐18 (CK‐18). The prevalence of THF was 13.4%. uTHF was found in 11 men (2.9%), the pattern was bilateral in four while other four had bTHF in the other testis. pTHF was detected in eight cases (2.1%), and except for one case with Klinefelter's syndrome, pTHF was in all cases occurring unilaterally. bTHF was detected in 32 cases (8.4%), bilaterally in 17 (53%). Pronounced THF was significantly associated with testicular malignancy. CK‐18 was detected in more azoospermic men with sperm production in ≤50% seminiferous tubules than in azoospermic men with spermatogenesis in ≥90% of seminiferous tubules and normal controls (p < 0.05). Unfortunately, TM detected histologically was not detected in any patient expressing THF, and neither THF nor TM was detected in any of the patients examined for CK‐18. Sertoli cell dysfunction was not associated with testicular microlithiasis or hyperechogenic foci.

Testicular microlithiasis: Correlation with doppler sonography of testicular arteries and sperm function

PURPOSE

To determine the prevalence of testicular microlithiasis and its correlation with Doppler parameters of testicular arteries and sperm function.

METHODS

Reports of 1,200 consecutive scrotal sonographic examinations performed at our hospital were reviewed. Patients diagnosed with testicular microlithiasis were recalled for detailed scrotal sonographic examination, including Doppler sonography and sperm function. The same examinations were performed in an age-matched control group and the findings compared.

RESULTS

Testicular microlithiasis was found in 64 cases (5.3%). Doppler sonography showed mean resistance index, Vmax, and Vmin of 61.1 ± 9.3%, 18.2 ± 4.7 cm/s, and 7.7 ± 2.3 cm/s, respectively, in the testicular microlithiasis group versus 62.4 ± 10.4%, 18.4 ± 5.7 cm/s, and 7.3 ± 2.4 cm/s, respectively, in the control group (p = 0.49, 0.84 and 0.35, respectively). Sperm function tests demonstrated sperm count, motility, and normal morphology (normal oval head) of 29.6 ± 20.4 × 10(6) /mL, 35.3 ± 16.2%, and 44.4 ± 12%, respectively, in patients with testicular microlithiasis versus 54.3 ± 22.4 × 10(6) /mL, 50.2% ± 14.4%, and 66.4 ± 11.6% in control subjects (p < 0.02).

CONCLUSIONS

Prevalence of testicular microlithiasis of 5.3% in Jordanian patients is similar to what has been reported in the literature. Testicular microlithiasis does not have a significant effect on Doppler parameters of testicular arteries. The apparent impairment of sperm function in patients with testicular microlithiasis warrants further studies. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:474-479, 2016.

The Diagnostic Value of Ultrasound in Differentiating Obstructive from Nonobstructive Azoospermia Based on the Presence of Testicular Microlithiasis

A total of 32 azoospermic men aged 24 to 54 years were studied perspectively at King Hussein Medical Center.Patient history, semen analyses, hormonal status, and testicular volume were analyzed.High-resolution ultrasound scan machine with a 7.0-MHz transducer was performed on all patients to detect testicular microlithiasis.Testicular biopsy was per formed on all patients.Based on the clinical findings outlined in this article, it is concluded that testicular ultrasound examination is a simple, rapid, and non-invasive diagnostic tool in evaluating the testicular body.Based on testicular volume, hormonal status, presence, and degree of testicular microlithiasis, ultrasound scanning has a significant role in differentiating OA from NOA.

Ultrasound demonstration of testicular microlithiasis in pediatric patients: is there an association with testicular germ cell tumors?

BACKGROUND

There is suggestion that testicular microlithiasis predicts risk of testicular malignancy, especially testicular germ cell tumors. This association remains uncertain.

OBJECTIVE

We retrospectively reviewed testicular germ cell tumor occurrence in patients with testicular microlithiasis to assess this association and determined the prevalence of testicular microlithiasis in symptomatic boys.

MATERIALS AND METHODS

This study was IRB and HIPAA compliant. Two-thousand six-hundred twenty-five testicular US exams performed on 2,266 children (younger than 19 years of age) in our institution from 2000 through 2011 were reviewed for presence of testicular microlithiasis and masses. Testicular microlithiasis was defined as presence of five or more testicular microcalcifications on a single US image. Incidence of testicular germ cell tumors was calculated in a group of patients with testicular microlithiasis and in a control group without testicular microlithiasis. Relative risk, odds ratio, 90% and 95%CI were calculated.

RESULTS

Eighty-seven patients out of 2,266 had testicular microlithiasis. One child was found to have both testicular germ cell tumor and testicular microlithiasis. In 2,179 children without testicular microlithiasis, 8 had testicular germ cell tumors. Incidence of testicular microlithiasis was 3.8%. Incidence of testicular germ cell tumors in testicular microlithiasis patients was 1.2%, and 0.38% in non-testicular microlithiasis patients. Relative risk of testicular germ cell tumors in testicular microlithiasis patients vs. non-testicular microlithiasis patients was 3.13 (90%CI: 0.55-17.76; 95%CI: 0.40-24.76), odds ratio 3.16 (90%CI: 0.55-18.32; 95%CI: 0.39-25.5).

CONCLUSION

There is no association between testicular microlithiasis and testicular germ cell tumors. We had hoped to do a meta-analysis, but only two studies had a sufficient case control group of non-testicular microlithiasis patients.

Clinical aspects of testicular microlithiasis in boys: a review

OBJECTIVE

After review of the pediatric literature, we report on the prevalence of testicular microlithiasis and its relation with benign and malign entities. We provide a guideline for the management of boys with testicular microlithiasis.

MATERIALS AND METHODS

The databases searched were Medline, Web of Science, Embase and the Cochrane Library. Data on the rates of testicular microlithiasis were collected and from each study information was extracted on the study population according to country, study design, diagnostic method, type of patient, number of patients, age, associated anomalies, additional diagnostic methods and follow-up information. From the 472 articles, we selected 126 articles as potentially relevant, of which 57 were included.

RESULTS

In asymptomatic boys, the prevalence of testicular microlithiasis is 4.2% and in symptomatic referrals it is 1.6%. The development of a testicular malignancy is occasionally reported after diagnosis of testicular microlithiasis. The management of boys with testicular microlithiasis varies widely. Most authors recommend regular self-examination, and some perform testicular ultrasound and/or screen tumor markers.

CONCLUSION

The prevalence of testicular microlithiasis in boys varies between 1.1% and 4.2%. For follow-up, regular self-examination is advised from the age of 15 years.

Testicular microlithiasis: is there a need for surveillance in the absence of other risk factors?

OBJECTIVE

Ultrasound surveillance of patients with testicular microlithiasis (TM) has been advocated following the reported association with testicular cancer. The aim of this study was to assess the evidence base supporting such surveillance.

METHODS

Formal literature review identified cohort studies comprising at least 15 patients followed up for at least 24 months. Combining an institutional audit with the identified studies in a pooled analysis the incidence of new cancers during the surveillance period was evaluated.

RESULTS

Literature review identified eight studies. Our institutional audit comprised 2,656 men referred for scrotal ultrasound. Fifty-one men (1.92 %) with TM were identified, none of whom developed testicular cancer (mean follow-up: 33.3 months). In a combined population of 389 men testicular cancer developed in 4. Excluding 3 who had additional risk factors, only 1 of 386 developed testicular cancer during follow-up (95 % CI 0.05-1.45 %).

CONCLUSIONS

Ultrasound surveillance is unlikely to benefit patients with TM in the absence of other risk factors. In the presence of additional risk factors (previous testicular cancer, a history of maldescent or testicular atrophy) patients are likely to be under surveillance; nonetheless monthly self-examination should be encouraged, and open access to ultrasound and formal annual surveillance should be offered.

KEY POINTS

• The literature reports a high association between testicular microlithiasis and testicular cancer. • Our study and meta-analysis suggest no causal link between microlithiasis and cancer. • In the absence of additional risk factors surveillance is not advocated. • In the presence of additional risk factors surveillance is recommended. • Such surveillance is primarily aimed at engaging patients in regular follow-up.

Implications of incidental finding of testicular microlithiasis in paediatric patients

OBJECTIVE

To improve understanding of the implications of testicular microlithiasis (TM) in paediatric patients diagnosed incidentally on scrotal ultrasonography (US).

PATIENTS AND METHODS

31 boys aged 4-14 years diagnosed with TM based on US between February 2000 and September 2007 were retrospectively reviewed. Demographic data, indications for US, associated inguino-scrotal pathologies and follow-up data were collated.

RESULTS

A total of 59 testes were evaluated. Fifty-four had TM at US. The most common indication for US was scrotal swelling (n = 17). Twenty patients (65%) had at least one associated inguino-scrotal pathology related to patent processus vaginalis, with cryptorchidism being the most frequently observed (39%). On follow up (mean 39.6 months), 6 patients documented decrease or resolution of TM, while 2 showed increase in TM density. No testicular malignancy was observed during follow up.

CONCLUSIONS

TM is commonly diagnosed incidentally on US in paediatric patients. A literature review revealed few case reports on its association with testicular malignancy and a prevalence of 4.2% among asymptomatic boys. The spontaneous resolution of TM supports degeneration of seminiferous tubules as the possible cause and further questions its malignant implication. An appropriate surveillance scheme would require involvement of a well-informed patient and parent with good compliance on testicular self-examination.

Testicular microlithiasis: Is there an agreed protocol?

This review addresses the issues on etiopathogenesis of testicular microlithiasis (TM), associated clinical entities, evaluation and follow-up of patients with TM. A literature search of Medline/PubMed was carried out using the keywords 'testicular microlithiasis' and 'testicular calcifications' for published data in English language on TM from 1970 to 2006. TM is an uncommon entity among adult males, resulting from intratubular calcifications. The reported incidence of TM is highly variable. With the increasing frequency of ultrasound examination in scrotal and testicular conditions and with the advent of high frequency transducers, TM is increasingly being reported. TM is associated with many benign and malignant conditions of testes but the possible association of TM with testicular cancer has been a matter of concern. Though a few sporadic cases of testicular malignancies have been reported, it is believed that a conservative approach is warranted in the absence of high risk factors, in view of the low risks for invasive cancers. There is no uniform protocol for the evaluation and follow-up of the patients with TM. Those with high risk factors like contralateral testicular tumour, chromosomal anomalies, gonadal dysgenesis, cryptorchidism and definite ultrasound pattern of TM should be advised to have further evaluation. Incidentally detected asymptomatic TM during ultrasound examination does not warrant aggressive measures and it can be followed with self examination.

Occurrence of testicular microlithiasis in androgen insensitive hypogonadal mice

BACKGROUND

Testicular microliths are calcifications found within the seminiferous tubules. In humans, testicular microlithiasis (TM) has an unknown etiology but may be significantly associated with testicular germ cell tumors. Factors inducing microlith development may also, therefore, act as susceptibility factors for malignant testicular conditions. Studies to identify the mechanisms of microlith development have been hampered by the lack of suitable animal models for TM.

METHODS

This was an observational study of the testicular phenotype of different mouse models. The mouse models were: cryptorchid mice, mice lacking androgen receptors (ARs) on the Sertoli cells (SCARKO), mice with a ubiquitous loss of androgen ARs (ARKO), hypogonadal (hpg) mice which lack circulating gonadotrophins, and hpg mice crossed with SCARKO (hpg.SCARKO) and ARKO (hpg.ARKO) mice.

RESULTS

Microscopic TM was seen in 94% of hpg.ARKO mice (n=16) and the mean number of microliths per testis was 81+/-54. Occasional small microliths were seen in 36% (n=11) of hpg testes (mean 2+/-0.5 per testis) and 30% (n=10) of hpg.SCARKO testes (mean 8+/-6 per testis). No microliths were seen in cryptorchid, ARKO or SCARKO mice. There was no significant effect of FSH or androgen on TM in hpg.ARKO mice.

CONCLUSION

We have identified a mouse model of TM and show that lack of endocrine stimulation is a cause of TM. Importantly, this model will provide a means with which to identify the mechanisms of TM development and the underlying changes in protein and gene expression.

Testicular microlithiasis in Taiwanese men

Testicular microlithiasis (TM) is an unusual ultrasonographic manifestation in testicular parenchyma. Limited information is available about TM in Taiwanese men. We performed a retrospective analysis to investigate the characteristics of TM and its association with testicular cancer and infertility in Taiwan. Male patients who had received scrotal ultrasonography because of scrotal symptoms or infertility between January 2000 and December 2003 were recruited. The incidence of TM was 7.6%. Both testicular microlithiasis and testicular cancer occurred chiefly in the third decade. Patients with TM exhibit a higher chance of testicular cancer (6% vs. 0.9%). No local field effect between TM and testicular cancer was observed. Testicular microlithiasis severity is not positively correlated with sperm quality and sterility. Forty-eight patients (32%) were available at follow-up. No patient developed a testicular tumor or elevated tumor markers (AFP, beta-hCG) during follow-up. We suggest monthly self-examination, annual scrotal ultrasonography and tumor markers screening between the age of 20 and 30 years of patients with TM.

Testicular microlithiasis in patients with scrotal symptoms and its relationship to testicular tumors

OBJECTIVES

To evaluate in a prospective study the coexistence of testicular microlithiasis with various scrotal pathologies and the relationship with testicular tumors in symptomatic patients presenting with various scrotal complaints.

METHODS

A total of 197 male patients of reproductive age who applied to our clinic between December 2004 and June 2005 with various scrotal complaints were included in the study. Patient complaints were of pain, swelling, smallness of the testes, and infertility. Patients were evaluated according to their medical history, scrotal ultrasonograms, tumor markers, and hormone profiles after physical examination. Independent t test and Fisher's exact test were used for statistical analysis.

RESULTS

The mean (+/-SD) age of the 197 patients was 28.3 +/- 8.5 years. Pathologic findings were testicular tumors (1.8%), cryptorchidism (3.5%), varicoceles (75%), hydroceles (9.8%), epididymal cysts (9%), and atrophic testes (0.9%). Testicular tumors were found in 4 patients, and testicular microlithiasis was observed in 3 (75%) of these patients. Testicular microlithiasis ratios were determined as 25% in cryptorchidism, 6.5% in varicocele, 23% in hydrocele, 10% in epididymal cyst, and 50% in atrophic testes. The rate of testicular microlithiasis was significantly higher in patients with testicular tumors. The mean follow-up of patients was 19.5 months (range, 16 to 23 months), during which no new cancer case was detected.

CONCLUSIONS

Testicular microlithiasis was more frequently observed in patients presenting with mass lesions and testicular tumors. Our findings suggest that symptomatic patients should be warned and kept aware of this issue, particularly if they have risk factors for testicular cancer.

Association between testicular microlithiasis and primary malignancy of the testis: our experience and review of the literature

PURPOSE

The aims of this study were to evaluate the association of testicular microlithiasis with testicular neoplasm, to assess the accuracy of ultrasonography (US) in comparison with histology in detecting microlithiasis, and to identify the prevalent cytohistological features that accompany testicular cancer.

MATERIALS AND METHODS

Between 2004 and 2005, 14 patients were referred to us for US examination, 13 of whom underwent surgery for testicular cancer. Their age ranged from 19 to 43 years, except for one patient aged 60. US findings and histological examination were compared to assess the accuracy of US in detecting microlithiasis associated with testicular cancer.

RESULTS

In two patients (15.3%), microlithiasis had been detected in a previous US examination, and two patients (15.3%) had altered sperm function. At US examination, testicular cancer was associated with microlithiasis in seven out of 13 patients (53.8%) (the distribution pattern of microlithiasis was intranodular in two, perinodular in two and both intra-and perinodular in three), and colour-Doppler US showed perinodular and intranodular vascularity. Histological evaluation identified nine seminomas, two mixed germ-cell tumours, one embryonal carcinoma, one yolk-sac tumour and one benign Sertoli-cell tumour. In nine (69.2%) patients, microlithiasis was confirmed at histologic evaluation, and its distribution was intranodular in two, perinodular in five and both intra-and perinodular in two. Tubular hyalinisation was demonstrated in 12 out of 13 patients (92.3%).

CONCLUSIONS

Testicular microlithiasis and poor sperm function represent risk factors for testicular cancer: in our study, 30.6% of the patients who developed cancer presented these features. At US examination, testicular microlithiasis is often associated with testicular cancer (53.8%). A high accuracy has been demonstrated for US in detecting microlithiasis (53.8%) compared with histological evaluation (69.2%). At histology, tubular hyalinisation (92.3% of cases) is, with testicular microlithiasis, the most frequent finding in the parenchyma adjacent to testicular cancer.

Calcificaciones intratesticulares en la edad pediátrica

INTRODUCTION

Testicular microlithiasis (TM) represents an uncommon occurrence at paediatrics with a radiological incidence between 0.16 to 0.6% according to reports. The greater use of ultrasound as well as the availability of high-frequency probes has increased the number of incidental TM being diagnosed.

MATERIAL AND METHOD

From January 1998 to October 2002 seven children, aged 9 to 13 years (average 11 years and 1 months), were diagnosed of MT in our department. Sonographic appearance was hyperechogenic multiple small foci of 1-3 mm without acoustic shadowing of the testicular parenchyma.

AIM

To evaluate sonographic patterns of TM, their associations, clinical consequences and to determine their management.

RESULTS

All children were asymptomatic and the reasons for the ultrasound were: cryptorchism (3), short height (1), gynecomastia (1), varicocele (1) and scrotum trauma (1). It should be noted that 3 of the cases showed bilateral TM. Out of 10 testicles with TM, 8 met classic testicular microlithiasis (CTM) criteria (at least one image that showed five or more microliths in either or both testes) and 2 had limited testicular microlithiasis (LTM) (to have at least one microlith). Clinical and radiological follow-up is being performed annually, ranging from 18 months to 6 years, during which there hasn't been progression or regression in the number of TM or in their distribution. In none of these cases there has been shown a related testicular cancer.

CONCLUSIONS

In other broad reviews it has been shown that there is no evidence to suggest that the TM have to be considered as premalignant lesions by themselves. However, the association among TM and cancer exists. Because of that, and due to the lack of consensus, we recommend annual clinical and radiological (ultrasound) follow-up until puberty, and thereafter the patient should be informed of unknown natural history of this condition. We do not recommend more invasive procedures such as biopsy except: 1) apart form the TM there is a change in the echogenicity or 2) if there is a change in the number or distribution of the TM.

Testicular microlithiasis: what does it mean clinically?

OBJECTIVE

To review our current practice of follow-up for boys with testicular microlithiasis (TM), an uncommon condition characterized by calcification within the seminiferous tubules, detected by ultrasonography (US); TM has been associated with both benign and malignant conditions of the testes but the natural history of TM in children remains unclear.

PATIENTS AND METHODS

All boys diagnosed with TM over a 14-year period were included in this study. A search of the radiology database was carried out using the keywords 'testicular microlithiasis' and 'testicular calcification'. A retrospective case-note review was then used to determine age at diagnosis, presenting symptoms, indication for testicular US, outcome and follow-up. We also searched Medline/PubMed, using the same keywords for published data on TM from 1970 to 2006.

RESULTS

Over the study period 711 testicular scans were taken in 623 patients; seven cases (1.1%) of TM were identified. The mean (range) age at presentation was 12 (7-15) years. The presenting symptoms were testicular pain (three), undescended testes (two), hydrocele (one) and asymptomatic scrotal swelling (one). In five cases the TM was bilateral and in two a solitary kidney was identified. Only one patient had tumour markers measured (beta-human chorionic gonadotrophin and alpha-fetoprotein) and these were within normal limits. On yearly US follow-up, the TM was less prominent in one patient, unchanged in four and two were lost to follow-up. Three patients are currently on yearly US follow-up while two are under the care of adult general surgeons. The analysis of reports published to date indicated that malignancy only develops when TM is associated with other predisposing factors.

CONCLUSION

There is no convincing evidence that TM alone is premalignant. However, when it accompanies other potentially premalignant features we recommend annual US follow-up.

Testicular microlithiasis identified ultrasonographically in Japanese adult patients: prevalence and associated conditions

OBJECTIVES

To determine the prevalence of testicular microlithiasis (TM) seen by testicular ultrasonography (US) in Japanese adult men referred for andrologic symptoms and evaluate associations of TM with pathologic conditions.

METHODS

For 7 years, US was performed in 969 patients (mean age 40.9 years) at one institution. The patients were divided into groups with infertility (n = 550), unilateral testicular tumor (n = 46), or other andrologic conditions (n = 373). TM was identified as multiple small hyperechogenic foci. In the tumor group, only images of the tumor-free testis were reviewed. Patients with TM accompanying tumor or infertility completed follow-up questionnaires and US examinations.

RESULTS

TM was diagnosed in 46 patients (mean age 38.5 years, range 23 to 75). The prevalence of TM was 17.4% in the tumor group, 5.6% in the infertility group, and 1.9% in the other-conditions group. TM was associated with testicular tumor and infertility, but not with other conditions. In patients with unilateral testicular germ cell tumor, the prevalence of carcinoma in situ in the contralateral testis was greater when TM was present in that testis (2 of 8 patients) than when TM was absent (0 of 32, P = 0.0037). No new testicular tumor developed subsequently. In the infertility group, the 31 patients with TM showed no subsequent testicular tumor development, and neither patient undergoing testicular biopsy had carcinoma in situ.

CONCLUSIONS

TM, as demonstrated by US, was associated with infertility, as well as testicular tumor. TM in a testis contralateral to a unilateral testicular germ cell tumor may increase the risk of carcinoma in situ.

Testicular Microlithiasis in Association with Pseudoxanthoma Elasticum

PURPOSE

To determine the presence of testicular microlithiasis in male subjects with pseudoxanthoma elasticum (PXE).

MATERIALS AND METHODS

Institutional review board approval was obtained for the prospective and retrospective components of this HIPAA-compliant study. Informed consent was obtained from all patients or their parents. Testicular ultrasonography (US) was performed in eight men aged 29-56 years and in one 13-year-old boy, all with confirmed PXE. Two radiologists reviewed the US images by consensus for testicular microlithiasis, testicular masses, and additional testicular abnormalities. Testicular microlithiasis was judged to be classic when at least five microliths were seen on a single US image and to be limited when fewer than five microliths were seen on all obtained US images. Urologic physiologic examinations were performed. A history and/or symptoms of testicular disease also were recorded at the time of examination. Similarly, the testicular US images obtained in two additional men, aged 48 and 59 years, and in another 13-year-old boy were retrospectively reviewed. Histopathologic testicular analysis was performed in one autopsy case.

RESULTS

Of the 12 participants, 11 (92%) had classic and one (8%) had limited testicular microlithiasis. None of the 12 participants had evidence of testicular malignancy at US or physical examination. Histopathologic analysis at autopsy revealed intratubular microlithiasis without the calcification of elastic fibers in arterial walls that is characteristic of cutaneous PXE.

CONCLUSION

Study findings suggested an association between PXE and testicular microlithiasis. It is possible that the testicular microlithiasis in male subjects who have PXE is related to the underlying PXE abnormality.

Significance of Testicular Microlithiasis

INTRODUCTION

Testicular microlithiasis is an uncommon condition characterized by calcifications within the seminiferous tubules. The true prevalence in a normal population has not been defined.

METHODS

A review of the literature with emphasis on the connection between testicular microlithiasis and testicular malignancy was carried out.

RESULTS

Testicular microlithiasis is associated with different testicular pathologies, including testicular cancer. However, a direct causative connection between testicular microlithiasis and testicular pathologies is not supported by the literature.

CONCLUSIONS

Patients with testicular microlithiasis should be followed up regularly. Further investigations concerning the etiology of testicular microlithiasis remain to be done.

Testicular microlithiasis: a review and its association with testicular cancer

Testicular microlithiasis (TM) is an entity of unknown etiology that results in the formation of intratubular calcifications. It is of concern to the urologist because of its possible association with intratubular germ cell neoplasia and testicular germ cell cancer. Although commonly present in patients with germ cell tumors, there appears to be no definitive association with TM and cancer. Therefore, follow-up at this time should be dictated based on risk factors for developing testis cancer more than on the presence of TM.

Microlithiasis of the epididymis and the rete testis

Testicular microlithiasis is a well-defined clinical and pathologic entity easily diagnosed through testicular echography; however, its association with cancer and infertility is now under debate. Many efforts have been done in recent years to clarify the spectrum of lesions observed in testicular microlithiasis, but no published data as to the existence of a possible microlithiasis of the epididymis and the rete testis have been found. We have observed microlithiasis of the epididymis and the rete testis in surgical (8 epididymis and 6 testis) and autopsy specimens (12 cases). In decreased order of frequency, microliths of the proximal spermatic way were seen in rete testis, epididymal duct, and efferent ducts. Intraluminal, subepithelial, and interstitial microliths were localized along these segments of the spermatic way. Subepithelial microliths were the most frequently found. A granulomatous reaction around the interstitial epididymal microliths, mimicking malacoplakia, was observed in 1 case. The differential diagnosis of microliths includes corpora amilacea, Michaelis-Gutmann bodies, calcium deposits, hyaline globules, and parasites, like the giant kidney worm Dioctophyme renale. In infants and young adults, microlithiasis of the epididymis and the rete testis is frequently associated with alterations in the development of the proximal spermatic way. In elderly adults, it is related to ischemia and obstruction of the spermatic way.

Management of recurrence and follow-up strategies for patients with seminoma and selected high-risk groups

Seminoma is characterized by high sensitivity to both radiation and chemotherapy. Localized recurrences in the retroperitoneum after surveillance for stage I can be treated with radiotherapy; however, multiple or large bulky retroperitoneal recurrences or systemic metastasis requires cisplatin-based chemotherapy. Salvage chemotherapy for those who recur after initial CR to induction chemotherapy is based on ifosfamide- and cisplatin-containing regimens. Incomplete response or failure after induction chemotherapy requires high-dose chemotherapy and stem cell rescue. Patients with seminoma need long-term follow-up because of the possibility of late recurrence and the risk of a second primary tumor.

Raman Spectroscopic Analysis Identifies Testicular Microlithiasis as Intratubular Hydroxyapatite

PURPOSE

As diagnosed by ultrasonography, testicular microlithiasis is associated with various benign and malignant conditions. The molecular constitution of these microliths is largely unknown. Raman spectroscopy provides detailed in situ information about the molecular composition of tissues and to our knowledge it has not been applied to gonadal microliths. We analyzed the molecular composition of gonadal microlithiasis and its surrounding region using Raman spectroscopy in malignant and benign conditions.

MATERIALS AND METHODS

Multiple microliths from 6 independent samples diagnosed with gonadal microlithiasis by ultrasound and histologically confirmed were investigated by Raman spectroscopy. The samples included 4 testicular parenchyma samples adjacent to a germ cell tumor (4 seminomas), a gonadoblastoma of a dysgenetic gonad and testicular biopsy of a subfertile male without malignancy.

RESULTS

Raman spectroscopic mapping demonstrated that testicular microliths were located within the seminiferous tubule. Glycogen surrounded all microliths in the samples associated with germ cell neoplasm but not in the benign case. The molecular composition of the 26 microliths in all 6 conditions was pure hydroxyapatite.

CONCLUSIONS

Microliths in the testis are located in the seminiferous tubules and composed of hydroxyapatite. In cases of germ cell neoplasm they co-localize with glycogen deposits.

Testicular microlithiasis: clinical significance and review of the literature

Testicular microlithiasis (TM) is an uncommon condition characterized by calcium deposits within the seminiferous tubules. On ultrasound (US), it is seen as multiple, uniform, nonshadowing echogenic foci in the testis. Although its true prevalence in the general population is still unknown, reported prevalences range from 0.6 to 9%. The TM is often associated with germ cell tumor (GCT) or intratubular germ cell neoplasia. The incidence of GCT in patients with TM was reported as 6-46%. There are several reports demonstrating interval development of GCT in patients with TM. These may suggest a premalignant nature of TM; however, more recent studies show a lower incidence of associated GCT and no interval development of tumor in relatively longer duration follow-up. Additionally, previously reported cases of interval tumor development had predisposing factors for testicular GCT. According to the recent literature, it is suggested that both TM and testicular GCT may be caused by a common defect, such as tubular degeneration, and TM may present as a marker for such abnormalities; however, because of a high incidence of association with GCT, it is prudent to follow up patients with TM with physical examination and US at least annually and to encourage self-examination. The routine use of biochemical tumor markers, abdominal and pelvic CT, or testicular biopsy does not seem to be justified.

Testicular microlithiasis: histologic and immunohistochemical findings in 11 pediatric cases

Testicular microlithiasis (TM) is being recognized with increasing frequency because of the extensive use of ultrasound. TM has been linked to several pathological conditions of the testis, mainly with an increased risk for developing germ cell tumors. The pathogenesis of the microcalcospherites is unknown. We report a detailed morphologic and immunohistochemical analysis of 11 patients (age: 3 to 15 years) with TM. The microliths were related neither to the age of the children nor to the developmental stage of the testis. The microcalcospherites were PAS positive or collagen IV positive or surrounded by a collagen IV-positive band, extratubular structures consistently associated with double-layered annular tubules. Immature, smaller Sertoli cells commonly lined the inner layer of the annular tubules. Some microcalcospherites showed an interposed thin band of connective tissue cells between the concretion and the tubular basement membrane. The annular tubules seemed to result from progressive wrapping of the growing tubules around the concretions. Our findings favor the interpretation that the microliths are located outside the tubules and have been present there since very early stages of testicular development. The association of the calcospherites with Sertoli cells and annular tubules formation, like that of gonadal stromal tumor with annular tubules of the ovary and large cell-calcifying Sertoli cell tumor of the testis, favors the hypothesis that microliths may result from multifocal Sertoli cell dysfunction. Since both tumors are related to the Peutz-Jeghers syndrome, it is proposed that TM may result from the same genetic abnormalities. It is unclear how this may be related to the development of germ cell tumors. However, the presence of calcospherites in gonadoblastoma may indicate a combined Sertoli cell and germ cell derangement in the genesis of TM.

Does testicular microlithiasis matter? A review

Radiologists who regularly undertake ultrasound of the testes will occasionally encounter testicular microlithiasis (TM). Currently, the management of a patient with TM is a conundrum for clinician and radiologist alike: there are reported associations between TM and primary testicular malignancy and infertility. However, there is no consensus on the appropriate follow-up (clinical, radiological or otherwise) of patients with TM. Furthermore, it is not clear whether the incidence of de novotumours is increased in patients with pre-existing TM. Similarly, there is limited evidence to support the association with infertility. Not surprisingly, algorithms for the follow-up of patients with TM on ultrasound have been difficult to formulate.

Testicular microlithiasis: prospective analysis of prevalence and associated tumor

PURPOSE

To evaluate testicular microlithiasis (TM) prospectively with modern state-of-the-art equipment.

MATERIALS AND METHODS

Information concerning indication for examination, presence and degree of TM, presence of testicular tumor, and patient age was prospectively recorded for all patients referred for scrotal ultrasonography between 1996 and 1999. High-frequency linear transducers (7.5 MHz or higher) were used. TM was divided into classic (CTM) and limited (LTM) on the basis of the presence of five or more microliths on one or more images of the testes. Fisher exact tests were used for determining significant differences in proportions.

RESULTS

Data in 1,079 patients were analyzed. The overall prevalence of TM was 18.1% (195 of 1,079). Forty (3.7%) patients had CTM, and 155 (14.4%) had LTM; 15 (1.4%) had tumors visible at US. Tumors were present in three (8%) of 40 patients with CTM (seminoma in two, embryonal cell in one), nine (5.8%) of 155 with LTM (seminoma in six, mixed germ cell in one, Leydig cell in two), and three (0.3%) of 884 with no TM (seminoma in two, other in one). There was no difference between CTM and LTM (P =.72) in the rate of coexisting tumor. There was a significant difference between no TM and CTM or LTM (P </=.001) in the rate of coexisting tumor. Eighty percent (12 of 15) of patients with tumor at presentation had CTM or LTM.

CONCLUSION

Approximately one of 27 patients had CTM, and one of seven had LTM. Although a majority of patients with testicular tumors had coexistent TM, more than 90% with TM (both CTM and LTM) did not have tumor at presentation.

Effects of testicular microlithiasis on Doppler parameters: report of three cases

BACKGROUND

Testicular microlithiasis is a rare, usually asymptomatic, non-progressive disease of the testes associated with various genetic anomalies, infertility and testicular tumors. According to our literature search, there is no specific data about Doppler findings in this disease.

CASE PRESENTATION

Doppler findings of three cases of testicular microlithiasis during last two years in our institution are presented.

CONCLUSIONS

Although our hypothesis was to find increased Doppler parameters due to intratesticular arterial compression, our findings suggest that there are no Doppler findings specific to testicular microlithiasis.

[Intratesticular calcifications: clinical significance]

OBJECTIVE

[corrected] To evaluate the clinical-pathological significance of the intratesticular calcification.

MATERIAL AND METHODS

We analyzed by scrotal U.S., transducer 6.5 Mhz, the patients that consulted about testicular painful, infertility or intrascrotal deformity. Biopsy was effectuated when detected size modification of testicles, and central or focal calcifications. Also was done the classics tumoral markers. We founds 16 patients with microlithiasis over 24 testicles with these pathology. Previous antecedents: infertility 6 cases, testicular devolvulations surgery 5c, bilateral orchidopexy 3c and unilateral epididymitis 2c. The calcifications was classified in: peripheric or central follow-up 26.4 months.

RESULTS

Associated pathology: a) Bilateral cryptorchidism: 4 testicles. b) Testicular tumors: 5 testicles. These tumors were biopsed: 3 seminomas, 1 embryonary carcinoma and 1 ca in situ. Both with negative biologic markers. The association with testicular tumor had an incidence of 20.83%. The central localization was detected in the 5 tumors, while the peripheric were 4 testis (cryptorchidism) and 15 with aspect of "snow storm". Histopathologically was observed eosinophilic bodies, with calcified nucleus, but not a exclusive features.

CONCLUSIONS

Is a benign condition, casual, whose clinical significance is a still enigma. The association with testicular tumor is 20.83% and associated pathology is 33%. We proposed a testicular biopsy in cases of microlithiasis focal, central or with previous pathology.

Testicular microlithiasis: US follow-up

PURPOSE

To determine in patients with testicular microlithiasis (TM) the short-term natural history of classic TM (CTM) and limited TM (LTM).

MATERIALS AND METHODS

In 104 patients, testicular microliths were identified on ultrasonographic (US) images; 39 patients had five or more microliths on at least one US image (criterion for CTM), and 65 patients had fewer than five microliths (criterion for LTM). Attempts were made to have all patients return for follow-up US to assess for change in TM or development of tumor.

RESULTS

Seven (18%) of the 39 patients with CTM and one (2%) of the 65 patients with LTM had tumor at presentation (P =.004). Among all 104 patients, follow-up US was performed in 72 patients (31 with CTM, 41 with LTM), with mean follow-up of 45 months (range, 12-90 months). None of these patients had interval development of testicular neoplasm. LTM did not progress to CTM in any patient. Progression in number of microliths was seen in two patients with CTM.

CONCLUSION

Patients with LTM have a lower prevalence of associated malignancy than do patients with CTM. The risk of developing malignancy in patients with isolated TM (LTM or CTM) is low at short-term follow-up. These results raise the question of the need for routine US in this patient population.

Testicular seminoma in a man with bilateral microlithiasis and a history of cryptorchidism

A case is presented of a young man with a history of bilateral cryptorchidism who presented with infertility. On investigation he was noted to have bilateral microlithiasis and left testicular seminoma. The possible association between microlithiasis and seminoma in patients with a history of cryptorchidism is discussed.

Testicular microlithiasis: prevalence and tumor risk in a population referred for scrotal sonography

OBJECTIVE

Considerable accrued evidence points to an association between testicular microlithiasis, intratubular germ cell neoplasia, and testicular tumor. This study assesses both the prevalence of testicular microlithiasis revealed on sonography in a referred population and the concurrent tumor risk.

MATERIALS AND METHODS

Over a 32-month period (April 1996 through November 1998), 4892 scrotal sonographic examinations were performed in 4819 patients at four referral centers. All patients underwent high-resolution (7- to 10-MHz) imaging. Using a computerized word search (n = 4102; testicular microlithiasis, calcification, microliths, calcific foci, tumor, neoplasm, cancer, hyperecho, hypoecho, heterogen, and carcinoma) and manual retrieval (n = 790), cases of tumor, testicular microlithiasis (>5 microliths per sonogram), and testicular microlithiasis plus tumor were pulled and retrospectively reviewed. The presence and type of tumor were confirmed at histology after orchidectomy.

RESULTS

Fifty-four tumors were found among 4892 scrotal sonograms (28 seminomas, 14 teratomas, 8 mixed germ cell tumors, 2 Leydig cell tumors, and 2 non-Hodgkin's lymphomas). Testicular microlithiasis was present in 33 patients, giving a prevalence of 0.68%. Concurrent tumor and testicular microlithiasis were detected in seven patients, a relative risk of tumor in testicular microlithiasis was 21.6-fold (95% confidence limits: 10. 6-fold, 44.2-fold). In one patient with testicular microlithiasis, a previous orchidectomy for mixed germ cell tumor had been performed (not included in the relative risk calculation).

CONCLUSION

In a referred population of 4819 patients the prevalence of testicular microlithiasis was 0.68% and the relative risk of concurrent tumor was 21.6-fold. Sonographic surveillance of testicular microlithiasis cases for tumor is mandatory.

Testicular microlithiasis in a UK population: its incidence, associations and follow-up

OBJECTIVES

To determine the incidence of testicular microlithiasis in men presenting for testicular ultrasonography, to identify any associated pathology (with particular reference to testicular neoplasia) and to report the follow-up of those patients in whom testicular microlithiasis was identified.

PATIENTS AND METHODS

In this retrospective study, the results of all testicular ultrasonography undertaken between July 1995 and March 1998 in a district general hospital were reviewed. The records of all patients diagnosed ultrasonographically to have testicular microlithiasis were retrieved and the pathology database was accessed for all testicular tumours diagnosed in the same period.

RESULTS

During the study period 2215 scans were taken; 34 cases of testicular microlithiasis were identified, giving an incidence of 1.4%. Thirty-one testicular tumours were removed during the same period. Of the 34 cases with testicular microlithiasis, five had histologically confirmed testicular tumours (15%). The incidence of testicular tumours in the scans showing no microlithiasis was 26 in 2181 (1.1%). The differential incidence of tumours in the two groups is statistically significant (P < 0.001, chi-square analysis). Patients with testicular microlithiasis but no tumour were followed up for a median (range) of 41 (19-54) months; no interval tumours have developed to date.

CONCLUSION

This study confirms an incidence of testicular microlithiasis comparable with that in other reported series, albeit in a selected population. There was a strong association between testicular microlithiasis and testicular tumours. Whether this is a causal relationship has yet to be determined. Careful clinical and ultrasonographic follow-up of these patients is therefore recommended until the significance of testicular microlithiasis is clear.

Testicular microlithiasis

Testicular microlithiasis is an uncommon condition that is characterized by calcifications within the lumina of seminiferous tubules. It is usually an incidental finding on high frequency scrotal sonography. Testicular microlithiasis is a benign condition but is associated with testicular malignancies. Recent reports support this association and suggest regular follow-up in these patients.

Identification of seminiferous tubule aberrations and a low incidence of testicular microliths associated with the development of azoospermia

OBJECTIVE

To evaluate the use of percutaneous testicular sperm aspiration in the assessment of azoospermia and its association with seminiferous tubule microliths.

DESIGN

Case report.

SETTING

Tertiary care fertility center in a university hospital.

PATIENT(S)

Male undergoing infertility evaluation.

INTERVENTION(S)

Testicular biopsy and percutaneous testicular aspiration.

MAIN OUTCOME MEASURE(S)

Serum hormone analysis, sperm concentration in semen, spermatogenesis in samples from testicular biopsies and aspirations, and microlith composition.

RESULT(S)

A patient presented for infertility evaluation with a history of severe oligospermia that progressed to azoospermia. The serum testosterone concentration (357 ng/dL) and LH concentration (9.2 mIU/mL) were normal and the serum FSH concentration (18.3 mIU/mL) was elevated. Testicular biopsy results indicated spermatogenic hypoplasia with limited spermatozoa. Seminiferous tubules obtained by percutaneous testicular aspiration were structurally aberrant, with multiple diverticula. Microliths averaging 120 microm in diameter were observed within and blocking the seminiferous tubules. The microliths were composed of calcium phosphate (hydroxyapatite) in both the core and peripheral regions. Electron microscopy revealed a high degree of collagen-like material within the peripheral zone.

CONCLUSION(S)

The presence of seminiferous tubule microliths is associated with the development of azoospermia. In patients with a low incidence of seminiferous tubule microliths and aberrant seminiferous tubule architecture, percutaneous testicular aspiration may provide a diagnostic advantage over testicular biopsy.

Testicular biopsy. Contemporary interpretation

Biopsy of the testis is not universally accepted in contrast with biopsies of other organs. The pathologist studies and reports on the pathophysiology of the testicular biopsy specimen. Methodology requires the inclusion of qualitative and quantitative studies, the evaluation of the lesion's evolution (prognosis), and, often, therapeutic advice regarding treatment. Cooperation between pathologists and clinicians optimizes the utility of the biopsy for the patient.

Testicular microlithiasis is associated with testicular pathology

OBJECTIVES

To evaluate the impact of testicular microlithiasis (TM) on male health by describing our experience. TM is an uncommon condition characterized by calcium deposits in the lumina of seminiferous tubules. These intratesticular calcifications appear as bright, 2- to 3-mm echogenic foci on testicular ultrasound (US).

METHODS

Patients diagnosed with TM by high-frequency testicular US over a 4-year period from two separate institutions were included in this study. Approximately 1100 testicular USs were performed (both hospitals combined) over the 4-year period. Patients were clinically identified by the characteristic appearance of TM on testicular US. Pathologic specimens were obtained in 14 (64%) of 22 patients.

RESULTS

Thirty-eight testicles (16 bilateral cases) in 22 patients were found to have TM. The incidence of TM was approximately 2%. Mean age at presentation was 29 years (range 8 to 63). Eight (36%) of 22 patients had testicular malignancies. Five (23%) of 22 patients were infertile. Three (14%) of 22 patients presented with unilateral necrosis of the testes due to spermatic cord torsion. Two patients had varicoceles, 1 patient had epididymitis, and another patient had torsion of an appendix testis. Previously unreported associations of TM and neurofibromatosis (1 patient) and acquired immunodeficiency syndrome (AIDS) (1 patient) were noted. No patient with TM later developed a testicular malignancy, yet the mean follow-up was only 31 months (range 1 to 108). One patient with unilateral TM developed bilateral TM, and 1 patient with bilateral TM subsequently developed unilateral TM. One patient developed spermatic cord torsion and testicular infarction 4 years after previously documented TM.

CONCLUSIONS

TM is usually diagnosed by testicular US performed for various indications. TM is an uncommon condition that is found in testes with both malignant and nonmalignant conditions. The association of TM and testicular malignancy suggests regular follow-up with testicular US examinations.

Testicular calcifications: incidence, histology and proposed pathological criteria for testicular microlithiasis

PURPOSE

Testicular microlithiasis is a clinical syndrome in which men present with innumerable testicular calcifications. Indirect evidence suggests that this syndrome may be associated with an increased risk of germ cell neoplasia. The incidence and types of testicular calcification in normal and diseased testes is unknown.

MATERIALS AND METHODS

A series of 131 orchiectomy specimens were reviewed, including 79 germ cell tumors, and 100 entirely embedded autopsy testes in men with no known testicular pathology.

RESULTS

Two types of calcifications were identified. Hematoxylin bodies, consisting of amorphous calcific debris, were present in 6 cases associated with germ cell tumors. In contrast, laminated calcifications were found not only in association with germ cell tumors (35 cases), but also in 2 of 4 cryptorchid testes and 6 of the remaining 145 testes (4%). Of these calcifications 61% were multiple. When laminated calcifications were associated with germ cell tumors there was an increased incidence of extension beyond the tunica albuginea (43 versus 21%) and lymphatic invasion (52 versus 17%, p = 0.046 and 0.012, respectively).

CONCLUSIONS

Testicular calcifications are heterogeneous. Hematoxylin bodies are specific for germ cell tumors but laminated calcifications, while more common in germ cell tumors, also occur in otherwise normal testes. The pathological criteria for testicular microlithiasis should include the identification of multiple laminated calcifications within seminiferous tubules.

Multi-institutional study of testicular microlithiasis in childhood: a benign or premalignant condition?

PURPOSE

Testicular microlithiasis, a rare ultrasonographic diagnosis in children, has been shown to coexist in benign and malignant conditions. The natural history of incidentally discovered testicular microlithiasis has not been well defined in the pediatric population. The concern that testicular microlithiasis may be a premalignant condition has been raised. Reports indicate as much as a 45% association of germ cell tumors with testicular microlithiasis at the time of tumor diagnosis and there have been 4 cases of interval testicular tumor development associated with preexisting testicular microlithiasis. To address this issue we performed a multi-institutional study to evaluate children with incidentally diagnosed testicular microlithiasis.

MATERIALS AND METHODS

Data on 26 patients with a mean age of 12.3 years at presentation with incidentally discovered testicular microlithiasis were collected from 7 institutions. Presenting scrotal conditions were reviewed. Two children with a previous testicular malignancy were excluded from study.

RESULTS

Followup ranged from 1 month to 7 years (mean 27.6 months). Testicular biopsy and tumor marker (alpha-fetoprotein and beta-human chorionic gonadotropin) determinations were performed in 9 and 15 patients, respectively. To date no testicular tumor has developed during clinical followup.

CONCLUSIONS

Our multi-institutional study has not yet shown a trend toward the malignant degeneration of incidentally diagnosed testicular microlithiasis in children. However, we still advocate close surveillance of patients with testicular microlithiasis, such as yearly testicular ultrasound, physical examination, and judicious tumor marker determinations. We propose that a registry be started to follow prospectively patients with testicular microlithiasis to define its significance better.

Testicular microlithiasis: association with male infertility

PURPOSE

We studied the frequency of testicular microlithiasis (TM) in a select group of otherwise healthy infertile men with abnormal semen.

METHODS

We reviewed scrotal sonography records of 180 consecutive patients with abnormal semen who were referred for evaluation of male infertility. The pampiniform plexus was evaluated for possible varicocele, and the testes were examined for the presence or absence of intratesticular calcifications and/or masses. Five patients with more than 5 echogenic foci per transducer field in either testis were identified. The medical records and sonograms of this subgroup of patients were analyzed.

RESULTS

Of the 180 patients, 5 (2.8%) had TM. Three patients with TM had concomitant small varicoceles; 2 others had a history of testicular maldescent. Two patients eventually became fertile.

CONCLUSIONS

Our results indicate a higher than expected frequency of TM in otherwise healthy infertile men. We speculate that the magnitude of hypospermatogenesis in patients with TM is variable and may relate to both the degree of testicular dysgenesis and the presence or absence of concomitant scrotal pathology (eg, scrotal varicocele and cryptorchidism).