Does testicular microlithiasis matter? A review

A review of multiparametric ultrasound imaging in the clinical setting: scrotal contents

The innovative techniques in ultrasound have added a new dimension to investigating superficially located areas such as the contents of the scrotal sac. High frequency transducers, improved technology with the addition of elastography, contrast enhanced ultrasound and microvascular imaging has resulted in a further improvement in diagnostic capabilities. The ability to clearly demonstrate the presence or absence of vascularity within the area under investigation adds an additional dimension to operator confidence in establishing the presence of infarction, global or segmental, or the walls and cavity of an abscess in the testis or epididymis. Increased vascularity of a tumor aids the differential diagnosis based on the flow dynamics of the microbubble contrast, benign lesions likely to retain contrast. Elastography has the ability to ascertain the stiffness of tissue, and when used in conjunction with other ultrasound methods adds to the understanding of the likelihood of a malignant abnormality being present. All the different techniques come under the umbrella term 'multiparametric ultrasound', with the application in the scrotal sac detailed in this article.

Is testis sparing surgery safe in patients with incidental small testicular lesions referring to a fertility center? A retrospective analysis reporting factors correlated to malignancy and long-term oncological outcomes

PURPOSE

To define predictors of malignancy after Testis sparing surgery (TSS) in patients referring to a fertility center with incidental small testicular lesions. Sub analyses were performed to assess predictors of Leydig cell hyperplasia and Leydig cell tumor.

MATERIALS AND METHODS

We performed a retrospective analysis of a single institutional database including patients treated with TSS between 2002 and 2020. All patients who underwent TSS as a first line surgical approach for incidentally detected lesions found during fertility evaluation were included.

RESULTS

Data of 64 patients were collected. The median follow up was 58 months and no recurrences were observed. At univariable logistic regression multifocal lesions, hypervascularization, microlithiasis, age and lesion size were significantly associated with malignancy. At multivariable logistic regression lesion dimension, hypervascularization and multifocal lesions were predictors of malignancy. Lesions smaller than 5 mm proved to be benign in 96.6% of the cases (32/33). Intraoperative color of the lesion and US pattern of vascularization were predictors at multivariable logistic regression for Leydig cell hyperplasia and Leydig cell tumor.

CONCLUSION

Ultrasonographic characteristics and intraoperative appearance of the lesion can predict the malignant nature of small testicular lesions, guiding their surgical management in patients referring to a fertility center. Based on our experience, clinicians may safely perform TSS in carefully selected patients.

Testicular ultrasound inhomogeneity is an informative parameter for fertility evaluation

Testicular volume (TV) is proposed to be a positive predictor of male fertility status, because of the relation known between the TV and the seminiferous tubule content. Independently of the measurement methodology, the role of TV and testicular ultrasound (US) assessments is still debated in andrological clinical practice. In this retrospective cohort study, we evaluated TV and testis US role in the diagnostic workup of andrological patients. All consecutive outpatients undergoing single-operator testis US (Modena, Italy) from March 2012 to March 2018 were enrolled, matching sonographic, hormonal, and seminal data. A total of 302 men were referred and evaluated for gynecomastia, suspected hypogonadism, couple infertility (CI), or sexual dysfunction. In the hypogonadal group, TV was lower compared to that in other groups (P < 0.001), and a significant, direct correlation between TV and testosterone level was observed in nonandrogen-treated patients (R = 0.911, P < 0.001), suggesting that testicular size could be related to the testosterone-secreting compartment. In the CI group, normozoospermic patients showed higher TV compared to men with impaired semen quality (P = 0.003) and azoospermia (P = 0.003). However, TV was not able to discriminate between patients presenting normal and altered semen quality. On the contrary, testis US inhomogeneity was more frequent in patients with impaired sperm quality (55.0%; P = 0.007) and azoospermia (40.0%; P = 0.012), compared to patients with normozoospermia (5%), identifying thereby the sonographic pattern as an informative parameter of the fertility status. Therefore, in the CI workup, US evaluation seems to be more informative than the TV assessment alone.

Mediastinal Germ Cell Tumor with Testicular Microlithiasis

Testicular microlithiasis (TM) is a condition in which punctate calcifications are present in the testicle. A case of a 29-year-old Saudi male who developed a cough, hemoptysis, and shortness of breath is presented in this report. A computed tomography (CT) scan of the chest revealed a large mediastinal mass. CT scans of the abdomen and pelvis were normal. Testicular ultrasonography (US) showed multiple, bilateral punctate echoes that are characteristic of TM. No primary testicular tumor was detected. Transthoracic needle biopsy of the mediastinal tumor was consistent with a mixed germ cell tumor. This is the seventh case of extragonadal germ cell tumor with TM.

Association between risk factors and testicular microlithiasis

Background

Testicular microlithiasis and its clinical significance are not fully understood. Testicular microlithiasis and risk factors have been associated with testicular cancer. The role of testicular microlithiasis is investigated.

Purpose

To investigate the association between testicular microlithiasis and socioeconomic and other pre-diagnostic factors.

Material and Methods

All men who had a scrotal ultrasound examination at the Department of Radiology, Vejle Hospital, during 2001–2013 were included. They were categorized as patients with and without testicular microlithiasis and compared with pre-diagnostic data from a nationwide registry. A total of 2404 men (283 [11.8%] with testicular microlithiasis and 2121 [88.2%] without testicular microlithiasis) were included. The association between testicular microlithiasis and pre-diagnostic conditions was investigated with logistic regression.

Results

Overall, we found no statistically significant differences in demographics, socioeconomic characteristics, or testicular diseases in men with and without testicular microlithiasis. Men with testicular microlithiasis had more often been treated for infertility (odds ratio [OR] 2.09, 95% confidence interval [CI] 0.84–5.24) and testicular torsion (OR 1.58, 95% CI 0.34–7.36) compared to men without testicular microlithiasis. We found no association between sexually transmitted diseases and testicular microlithiasis.

Conclusion

Treatment for infertility and torsion was non-significantly associated with testicular microlithiasis and no other association was found. These data do not suggest early exposure is related to testicular microlithiasis.

Effects of an anti-gonadotrophin releasing hormone vaccine on the morphology, structure and function of bull testes

Castration reduces aggressive and sexual behaviour and provides better carcass quality in bull calves. Vaccination against gonadotrophin-releasing hormone (GnRH) is used as an alternative to surgical castration for the purposes of reducing pain and distress in the animals. Currently, no anti-GnRH vaccine has been authorized for use in cattle in the European Union. The aim of the present study was to assess the effect of an anti-GnRH swine-specific vaccine (Improvac®, Zoetis, USA) on the morphology, structure and function of bull testes. Animals were vaccinated at days 1, 21 and 104 of the experimental period and were classified based on their live weight into the following two groups: LIGHT (172.9 ± 30.00 kg) and HEAVY (323.8 ± 37.79 kg). The scrotal circumference was measured on day 1 and prior to slaughter (day 164). At slaughter, the sperm motility and concentration in the caudae epididymis were assessed. Testes were weighed, measured and examined using ultrasound, and then tissue samples were collected and fixed in formalin. Histological and immunohistochemical studies were performed on the testes to measure the diameter of the seminiferous tubules and assess the testicular cell populations. The results revealed that suppression of testicular development was associated with the use of the Improvac® vaccine, which resulted in a smaller size of the testes and impaired spermatid production. However, the effect of Improvac® was more pronounced and consistent in calves vaccinated at a low live weight than at a heavy live weight, which suggested that vaccination is more effective when calves are vaccinated before or early during puberty. However, testes from calves vaccinated at a low live weight were more prone to the development of intraluminal concretions in the seminiferous tubules.

Elastography and diffusion-weighted MRI in patients with testicular microlithiasis, normal testicular tissue, and testicular cancer: an observational study

BACKGROUND

Ultrasound elastography is increasingly available in clinical practice. Recent studies showed higher velocity stiffness in testicular tumors compared to normal testicles.

PURPOSE

To evaluate ultrasound elastography in combination with the apparent diffusion coefficient measurements in diffusion weighted (DW) magnetic resonance imaging (MRI) in testicles. DW can be a useful tool in evaluating testicular malignancies. However, the relationship between velocity stiffness and MRI diffusion is not well established.

MATERIAL AND METHODS

We prospectively included 132 patients with testicular microlithiasis (n = 53), or normal testicular tissue (n = 53), or suspected for testicular cancer (n = 26). All 132 patients underwent ultrasonography including shear wave elastography and MRI diffusion coefficient examination of the scrotum.

RESULTS

No clinically relevant difference in velocity stiffness was found between normal and testicles with microlithiasis. There was a significant difference in stiffness between patients with testicular microlithiasis (0.78 m/s), normal testicular tissue (0.77 m/s), and patients with testicular cancer (1.95 m/s) ( P ≤ 0.001). Similarly, there was a statistically significant difference in MRI diffusion values between patients with testicular microlithiasis (0.978 × 10^-3mm²s^-1), normal testicular tissue (0.929 × 10^-3mm²s^-1), and testicular cancers (0.743 × 10^-3mm²s^-1) ( P < 0.01).

CONCLUSION

Patients with testicular microlithiasis had no malignant characteristics measured with shear wave elastography or MRI diffusion. MRI diffusion and elastography may be useful to preoperatively differentiate benign from malignant testicular lesions.

Prevalence and risk factors of testicular microlithiasis in patients with hypospadias: a retrospective study

BACKGROUND

It has been described that the incidence of testicular microlithiasis is high in several congenital disorders which may be associated with testicular impairment and infertility. Several reports have shown that a prepubertal or pubertal hormonal abnormality in the pituitary-gonadal axis was identified in some patients with hypospadias that is one of the most common disorders of sex development. However, exact prevalence or risk factors of testicular microlithiasis in patients with hypospadias have not reported so far. In the present study, to clarify the prevalence and risk factors of testicular microlithiasis in patients with hypospadias, a retrospective chart review was performed.

METHODS

Children with hypospadias who underwent testicular ultrasonography between January 2010 and April 2016 were enrolled in the present study. Severity of hypospadias was divided into mild and severe. The prevalence and risk factors of testicular microlithiasis or classic testicular microlithiasis were examined.

RESULTS

Of 121 children, mild and severe hypospadias were identified in 66 and 55, respectively. Sixteen children had undescended testis. Median age at ultrasonography evaluation was 1.7 years old. Testicular microlithiasis and classic testicular microlithiasis were documented in 17 children (14.0%) and 8 (6.6%), respectively. Logistic regression analysis revealed that presence of undescended testis was only a significant factor for testicular microlithiasis and classic testicular microlithiasis. The prevalence of testicular microlithiasis or classic testicular microlithiasis was significantly higher in children with undescended testis compared to those without undescended testis (testicular microlithiasis; 43.8% versus 9.5% (p = 0.002), classic testicular microlithiasis; 37.5% versus 1.9% (p < 0.001).

CONCLUSIONS

The current study demonstrated that the presence of undescended testis was only a significant risk factor for testicular microlithiasis or classic testicular microlithiasis in patients with hypospadias. As co-existing undescended testis has been reported as a risk factor for testicular dysfunction among patients with hypospadias, the current findings suggest that testicular microlithiasis in children with hypospadias may be associated with impaired testicular function. Conversely, patients with isolated HS seem to have lower risks for testicular impairment. Further investigation with longer follow-up will be needed to clarify these findings.

Bilateral methachronous testicular germ cell tumor and testicular microlithiasis in a child: Genetic analysis and insights. A case report

OBJECTIVES

To report our experience with a case of a child with bilateral testicular micro-lithiasis (TML) who developed bilateral metachronous testicular germ cell tumor (TGCT) and determine the most appropriate follow-up and care management in children with testicular micro calcifications in regards to the theoretical risk of testicular cancer.

CASE REPORT

A 12 year-old boy was diagnosed with TGCT and TML. Ten years after complete remission, he presented with a recurrence on the contralateral testis. Genetic screening was performed on both resected and the patient's karyotype was analyzed.

RESULTS

Blood karyotype was normal. Aberrations were found in the tumor karyotype. CGH array showed alterations in chromosome arm 12p.

DISCUSSION

TML is frequently associated with testicular malignancy in adults: in 16.9% of cases the normal contralateral testicle develops TML in TGCT. Recent works of literature find no relationship between TML and cancer in general, but in patients with additional risks, the relationship becomes stronger. Some authors suggest that environmental components and genetics are determinant factors. This is highly suspected in our reported case. It would seem that TML is not a precancerous lesion per se, but rather a marker of an at-risk situation. Long term evolution is uncertain and regular self-palpation that starts before puberty is the only way to ensure proper screening and monitoring.

CONCLUSION

TML have been suspected to be a sign of testicular dysgenesis syndrome, which yields a risk of developing TGCT in case of noxious associations. In patients with a history of TGCT contralateral TML is alarming and aggressive surgical management should be discussed. Therapeutic education of these patients on self-palpation is the best way to ensure proper follow-up.

Characteristics of symptomatic men with testicular microlithiasis - A Danish cross-sectional questionnaire study

Testicular microlithiasis (TML) is an incidental finding at ultrasonography of the scrotum. A link between testicular microlithiasis and testicular cancer has been suggested. However, the majority of studies are retrospective using ultrasonography with minor data on health status and life style characteristics. Our objective was to investigate if lifestyle and health are associated with TML. In 2014, we conducted a self‐administered questionnaire survey including 1538 men, who all due to testicular/scrotal symptoms had an ultrasound investigation of the scrotum during 2004–2013. The men were divided into men with TML and men without. The 23‐items questionnaire included items on age, height, weight, lifestyle (alcohol consumptions, smoking habits, workload, exercise and food), previous diseases in the testicles, pain and consumption of analgesics. The prevalence of TML was 12.8%. Overall, lifestyle factors did not vary between men with or without TML. However, men with TML did consume more crisp than men without. Development of TML was not associated to classic life style factors such as alcohol consumption, smoking habits, or mothers smoking during pregnancy. Also, age and height could not be linked to presence of TML. We did find, however, that men with TML experienced less physical activity and consumed more crisp than men without TML. Since ingestion of crisps has potential carcinogenic effect (acrylamide), this finding needs confirmation in a separate study.

Pulmonary Alveolar Microlithiasis

Pulmonary alveolar microlithiasis (PAM) is a genetic lung disorder that is characterized by the accumulation of calcium phosphate deposits in the alveolar spaces of the lung. Mutations in the type II sodium phosphate cotransporter, NPT2b, have been reported in patients with PAM. PAM progresses gradually, often producing incremental dyspnea on exertion, desaturation in young adulthood, and respiratory insufficiency by late middle age. Treatment remains supportive, including supplemental oxygen therapy. For patients with end-stage disease, lung transplantation is available as a last resort. The recent development of a laboratory animal model has revealed several promising treatment approaches for future trials.

Inter- and intraobserver agreement in detection of testicular microlithiasis with ultrasonography

BACKGROUND

Ultrasonography of the testis is a well-established diagnostic tool in detection of testicular microlithiasis (TML). Operator-dependent diagnostic variation related to skill, knowledge, and operator consistency are factors that influence detection of TML.

PURPOSE

To determine inter- and intraobserver agreement for detection of TML using ultrasonography for a group of physicians with no or limited experience compared to a group of experience senior radiologists.

MATERIAL AND METHODS

Between May and September 2014 a total of six observers evaluated 34 patients scrotal ultrasonography recorded from September to December 2013. The observers were blinded to patient history and previous ultrasonography. Three of the observers had no or limited experience with detection of TML, and three of the observers had more than 15 years of experience. Each observer reviewed all the scrotal ultrasonography recordings twice with a time interval of 3 months.

RESULTS

The inter-observer agreement showed substantial agreement and up to almost perfect agreement (κ = 0.86). Both the experienced and less experienced observers had a higher agreement in detecting and grading TML in their second reading.

CONCLUSION

The ultrasonography grading system of TML in this study showed to be reproducible, with an inter- and intraobserver agreement ranging between substantial agreement and up to almost perfect agreement with many years of experience not necessarily being essential.

Análise quantitativa da ecogenicidade testicular pela técnica do histograma de ovinos da baixada ocidental maranhense

A ultrassonografia é um método de diagnóstico por imagem que permite a avaliação de diferentes órgãos e estruturas corpóreas de maneira não invasiva. No entanto, a avaliação subjetiva das imagens caracteriza um dos grandes entraves na utilização desta técnica de diagnóstico, havendo necessidade de mecanismos que minimizem a subjetividade do exame e a divergência na interpretação dos achados ultrassonográficos. Desta forma este trabalho objetivou caracterizar a ecogenicidade do parênquima e mediastino testicular de ovinos utilizando a técnica do histograma escala-cinza. Foram utilizados 30 animais divididos em três grupos de acordo com a faixa etária (FE): de três a seis meses (FE1), sete a 12 meses (FE2), 13 a 18 meses (FE3) e realizadas varreduras testiculares nos planos frontal, sagital e transversal, elaborando ao final um histograma a partir das imagens ultrassonográficas. Observou-se que tanto a ecogenicidade do parênquima quanto a do mediastino testicular aumentaram gradativamente com a progressão das idades dos animais, com média e desvio-padrão de 95,00±19,05 e 94,35±18,82 para a ecogenicidade do parênquima do antímero direito e esquerdo, respectivamente, e 127,95±12,97 para o mediastino direito e 126,59±11,78 para o esquerdo. A técnica do histograma escala-cinza demonstrou ser um método eficiente na determinação da ecogenicidade testicular, possibilitando o estabelecimento de padrões de normalidade que venham a auxiliar pesquisas futuras no monitoramento do desenvolvimento testicular bem como na detecção de patologias. Para a regimes exclusivos de criação extensiva, como na baixada maranhense, representa ferramenta valiosa para sua utilização em projetos sociais do Estado que atendem a agricultura familiar.

[Testicular cancer - a matter of geography? Epidemiology and etiopathogenesis of germ cell tumors]

More than 90 % of testicular tumors are germ cell tumors. There is no doubt that ethnicity is one of the single overriding etiological factors in the development of these tumors. White males living in western industrialized countries, particularly in northern Europe show the highest incidence rates, whereas black males in Africa show the lowest. These differences are the result of interaction of genetic factors and exogenous noxious agents. Some of these agents are chemical substances with an estrogen-like effect. Many exogenous substances have been blamed for causing testicular cancer, but clear epidemiological evidence is lacking for most cases. Some well-established risk factors prevail, such as cryptorchidism, familial association, gonadal dysgenesis (intersex) and germ cell tumor in the contralateral testis. In terms of importance, overalimentation appears to outweigh occupation. The development of germ cell tumors is assumed to have an intrauterine origin through defect gonocytes which evolve into atypical germ cells of unclassified intratubular germ cell neoplasms. The trigger event is, however, the appearance of isochromosome 12p, which makes these cells aggressive and results in overt invasive testicular cancer.

Testicular microlithiasis: the importance of self-examination

AIM

  To explore the issue of appropriate management of testicular microlithiasis. We report the third ever case of tumour arising from a testis previously known to have microlithiasis in childhood and review the literature to provide an evidence-based approach to management of testicular microlithiasis.

METHODS

  Case report and review of previous literature.

RESULTS AND CONCLUSIONS

  Although there is a strong association between testicular microlithiasis and testicular malignancy at diagnosis, there are only three reported cases of subsequent tumour development in childhood. Testicular microlithiasis is an increasingly recognised entity. There is insufficient evidence in the current literature to support any regime of clinical surveillance. Self-examination is the most important factor in the early detection of testicular malignancy.

Testicular microlithiasis an ultrasound dilemma: survey of opinions regarding significance and management amongst UK ultrasound practitioners

OBJECTIVE

To establish whether there is a consensus regarding the significance of testicular microlithiasis and a strategy for managing patients with this condition, amongst ultrasound practitioners in the UK.

METHODS

An electronic questionnaire was distributed to 1482 members of the British Medical Ultrasound Society (BMUS), requesting information from ultrasound practitioners involved in scrotal ultrasound about their interpretation of the risk associated with testicular microlithiasis and their departmental or personal recommendations for managing patients with this condition.

RESULTS

Responses were obtained from 221 BMUS members. Analysis demonstrated a wide variation in the significance attributed to the discovery of testicular microlithiasis and the risk of subsequent development of testicular germ cell tumours. There was also great variation in strategies for management of patients with testicular microlithiasis, including the need for surveillance ultrasound, amongst ultrasound practitioners regardless of their job description.

CONCLUSION

Lack of consensus shown by this study highlights significant differences across the UK in managing patients with testicular microlithiasis and validates the importance of guidance currently being formulated by the European Society of Urogenital Radiology.

ADVANCES IN KNOWLEDGE

We believe that this is the first survey to be conducted amongst imaging specialists in the UK regarding testicular microlithiasis and demonstrates that there is currently no uniform practice in managing patients with this condition.

Evaluation of testicular tumour calcification with digital orchiography

OBJECTIVES

To analyse the calcification of testicular tumours in the orchiectomy specimens detected by digital orchiography obtained in a full-field digital mammography (FFDM) unit.

METHODS

Orchiectomy specimens of 37 consecutive patients were imaged by FFDM. Detected foci of calcification were stratified as: type 1, dense microcalcification; type 2, faint microcalcification; type 3, macrocalcification. Histopathology identified the tumour types, the presence of intratubular germ cell neoplasia (IGCN) and associated calcifications. Orchiography results correlated with the histopathology.

RESULTS

On orchiography, 32/37of the specimens (86 %) had co-existing foci of calcification. Histopathology results revealed foci of calcification in 23/37 (62 %) of orchiectomy specimens. Of the 20 IGCN cases, 80 % presented with calcifications on orchiography. Fifty-six percent (14/25) of type 1, 70 % (12/17) of type 2, and 30 % (2/6) of type 3 foci of calcification were observed in IGCN-positive cases.

CONCLUSION

This study classifies the morphology of testicular tumour calcification in three main groups by digital orchiography. In half of the testicular cancers, histopathologically proven IGCN is also found in addition to the index tumour. Type 2 foci of microcalcification detected by orchiography may be related to IGCN and may prompt further clinical assessment.

KEY POINTS

• Orchiography can detect and classify calcification in 86 % of testicular cancers. • Intratubular germ cell neoplasia (IGCN) co-exists in 54 % of testicular cancers. • Type 2 foci of microcalcification detected by orchiography may be related to IGCN. • Orchiography may play a possible future role in the diagnosis of testicular IGCN.

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.

Testicular Sarcoidosis: Sonographic Findings

Testicular sarcoidosis is a rare but benign entity. It is often mistaken for testicular neoplasm, leading to orchiectomy. It is, therefore, extremely important to identify and correctly diagnose testicular sarcoidosis on sonography to avoid unnecessary orchiectomy. This case study reports a young patient who had a prior history of unilateral orchiectomy for cryporchidism and presented with testicular lesions on the contralateral testis. He was later found to have skin lesions and chest symptoms that led to a diagnosis of sarcoidosis.

Testicular microlithiasis: prevalence and clinical significance in a population referred for scrotal ultrasonography

Purpose

Testicular microlithiasis (TM) is an uncommon pathologic condition that is commonly diagnosed by scrotal ultrasonography. Indirect evidence suggests that this syndrome may be associated with an increased risk of testicular malignancy and infertility.

Materials and Methods

A total of 1,439 patients undergoing scrotal ultrasound during a 6-year, 5-month period (January 2003 to May 2009) were retrospectively reviewed. Any possible association of TM with pathologic findings was assessed. Among patients with TM, further grading of TM with testicular cancer and semen analysis of the infertile group with TM were also performed.

Results

TM was diagnosed in 87 patients (6.0%) out of a total of 1,439. Of all established pathologic entities, only testicular malignancy and infertility were meaningfully associated with TM. There was no significant difference in the prevalence of testicular cancer between each grade. Seminal profiles (sperm count, motility, morphology, and white blood cell count) were not found to be statistically different between infertile men with and without TM.

Conclusions

The prevalence of TM in symptomatic men was found to be 6.0% with significant co-occurrence of TM, testicular cancer, and infertility. Further grading of TM does not seem to be essential with regard to the detection of patients with testicular cancer and TM. TM showed no significant effect on the seminal profiles of infertile men.

Another unusual presentation of McCune Albright syndrome with fibrous dysplasia, unilateral testicular enlargement, and testicular microlithiasis

We report on a 9-year-old boy with atypical McCune Albright syndrome who presented with polyostotic fibrous dysplasia, unilateral testicular enlargement without signs of sexual precocity, and bilateral testicular microlithiasis on sonography. This is the first report of a patient with an atypical form of MAS presenting with unilateral testicular enlargement not associated with sexual precocity, and with testicular microlithiasis.

The predictive value of testicular ultrasound abnormalities for carcinoma in situ of the testis in men at risk for testicular cancer

Testicular microlithiasis (TM) is sometimes observed during scrotal ultrasound examinations in men. It has been suggested that TM is more prevalent in testes of men at risk for testicular carcinoma in situ (CIS), the precursor cells of all testicular germ cell tumours (TGCT). We have performed a retrospective analysis of ultrasound images and additional clinical data of a selected cohort of men and have determined the risk factor of TM and other ultrasound abnormalities for testicular CIS. Between 2002 and 2007, 176 testicular biopsies were performed in men with abnormalities found on the scrotal ultrasound. TM was found in 76/176 men (43.2%) and CIS was diagnosed in 20 of these men (26.3%). Here, we focused on the group of 76 men with TM to determine additional risk factors, besides TM, for CIS. In both groups, those with and without CIS, reproductive hormones, scrotal ultrasound images and patient history were compared. Predictive ultrasound findings for CIS were TM (sensitivity 100%, 95% CI: 0.8-1.0; specificity 64.1%, 95% CI: 0.6-0.7; PPV 26.3%, 95% CI: 0.2-0.4) and within this group an inhomogeneous testicular parenchyma (OR 16.1, 95% CI 2.4-106.8; sensitivity 75.0%, 95% CI: 0.5-0.9; specificity 79.0%, 95% CI: 0.7-0.9; PPV 50.0%, 95% CI: 0.3-0.7). Other significantly ultrasound characteristics for CIS in this population with TM were clusters of TM (p = 0.02) and intra-testicular lesions (p = 0.01). Men with CIS were found to have significantly lower values of inhibin-B (p = 0.02). Clusters of TM, intra-testicular lesions and lower values of inhibin-B were not significantly different in logistic regression analysis. TM on scrotal ultrasound of men with risk factors for TGCT and men with clinical signs of testicular maldevelopment has a high predictive value for CIS. However, the predictive value of an inhomogeneous testicular parenchyma, besides TM, for CIS is much higher.

Testicular microlithiasis and carcinoma in situ overview and proposed clinical guideline

Testicular microlithiasis (TM) has been associated with testicular germ cell tumours (TGCTs) in adolescents and adults and with its precursor carcinoma in situ (CIS). A clear definition of TM and the need for further diagnostics and follow-up is lacking. We reviewed the literature of TM and its association with TGCT/CIS and current follow-up advises and propose a management approach based on associated risk factors for TGCT. In the literature, a wide variance of TM incidence is reported in different patient populations. A consensus concerning the malignant potential of TM has not been reached. In addition, a clear definition on TM is lacking. Although a correlation between TM and TGCT or CIS is found, precise management and follow-up schedules are absent. We suggest that all hyperechogenic foci smaller than 3 mm without shadowing should be named TM irrespective of their number. In addition, we suggest a management scheme for physicians encountering TM in daily practice. Our algorithm suggests taking a testicular biopsy in a selected patient population with at least one additional risk factor for TGCT. A long-term active follow-up schedule, including ultrasonography and physical examinations, is not indicated in the remaining patients with TM.

Increased prevalence of testicular microlithiasis in men with familial testicular cancer and their relatives

Testicular germ cell tumours (TGCT) cluster in families, but responsible genes remain unidentified. The association between testicular microlithiasis (TM) and testicular carcinoma in situ (CIS) suggests that TM may be a TC risk factor. We report testicular ultrasound findings in men with familial TGCT (FTGCT) and their unaffected relatives. A total of 81 men (48 affected and 33 unaffected) from 31 families with > or =2 TC cases underwent testicular ultrasound. Testicular microlithiasis was defined as either 'classic' (> or =5 microliths) or 'limited' (<5 microliths). Statistical analyses used Fisher's exact test and permutation testing. Testicular microlithiasis was more frequent in the contralateral testicles of men with a history of TGCT (affected men) than in unaffected men (48 vs 24%, P=0.04). The association appeared stronger for classic TM (21 vs 9%) than for limited TM (27 vs 15%). Testicular microlithiases were bilateral in six out of seven (87%) unaffected men. Among affected men, TM was not associated with histology, age at diagnosis or cancer treatment. Of the 31 families, 10 accounted for a majority (61%) of the TM cases identified (P=0.11). Testicular microlithiasis was more prevalent among FTGCT family members than described previously in the general population, and was more common among FTGCT cases vs unaffected blood relatives. Testicular microlithiasis appeared to cluster in certain families. These findings suggest both a familial predisposition to TM and an association between TM and FTGCT. If proven, this could be clinically important to men in FTGCT families, and may be useful in identifying specific genes involved in FTGCT.

Cancer risk in male factor-infertility

Severe forms of male-factor infertility are associated with an increased risk of testicular cancer and scrotal ultrasonography is widely used for diagnosis. In this study, 2172 male members of infertile couples referred to our Reproductive Medicine Unit were submitted to scrotal ultrasonography and 835 selected patients had been followed during a 2-year period. Eight out of nine neoplastic nodules found at the initial examination were unpalpable and discovered by ultrasonography. Ten tumoral lesions were found in 370 testicular biopsies performed for diagnostic purposes or to extract spermatozoa; and eight additional neoplastic lesions were discovered during the 2-year follow-up of 835 patients. The cumulative rate of neoplastic disease was 3.2%. Thirteen cases (1.5%) were malignant (12 germ cell tumours and one non-Hodgkin lymphoma of testicular origin); the remaining 14 were benign forms (Leydig cell tumours and hyperplasias, Sertoli cell nodules, adenomatoid tumours). Testicular volume (cut-off: 12ml) resulted weakly correlated with germ cell cancer (p=n.s., odds ratio 2.01) while low total sperm count (<40x10(6)) (p=0.002, odds ratio 8.4), previous cryptorchidism (p=0.04, odds ratio 7.5) and hypergonadotrophic hypogonadism (p=0.04, odds ratio 7.9) were associated with an increased risk. But a stronger correlation with germ cell cancer was found in the patients with some utrasonographic anomalies, i.e. testicular microlithiasis (p=0.0015, odds ratio 37.1) or larger calcifications not fitting the description of testicular microlithiasis (p<0.0001, odds ratio 69.5). Our findings indicate that scrotum ultrasonography should always be advised in subfertile men with <40x10(6) spermatozoa/ejaculate or hypergonadotrophic hypogonadism or previous cryptorchidism, and that particular care should be taken in the presence of testicular microlithiasis or testicular calcifications. These men should be aware of the existence of higher risk of testicular cancer and trained in testicular self-examination.

Testicular microlithiasis in siblings: clinical implications

Testicular microlithiasis is a relatively uncommon condition in children. It is characterized by the presence of microcalcifications within the testicular parenchyma. Although it is a benign finding, underlying diseases and other conditions must be ruled out because testicular microlithiasis has been found in association with both benign and malignant lesions in the testes and other tissues. We present two brothers with testicular microlithiasis, and highlight the prevalence, natural history, associated malignant conditions and follow-up recommendations of children diagnosed with testicular microlithiasis.

Regulation of spermatogenesis in McCune-Albright syndrome: lessons from a 15-year follow-up

CONTEXT

McCune-Albright syndrome (MAS) is a disorder caused by a post-zygotic gain-of-function mutation in the gene encoding the Gs-alpha protein. Sexual precocity, common in girls, has been reported in only 15% of boys, and little is known on the long-term evolution of MAS in males.

OBJECTIVE

In a boy with MAS, we studied spermatogenesis, testis histology, and immunohistochemistry with the aim to shed light on seminiferous tubule activity.

DESIGN

A boy who presented at the age of 2.9 years with sexual precocity, monolateral macroorchidism, increased testosterone levels, and suppressed gonadotropins was followed up until the age of 18.

RESULTS

Throughout follow-up testicular asymmetry persisted and gonadotropin and testosterone pattern did not change. At the age of 18, inhibin B was undetectable while alpha-immunoreactive inhibin was within normal range. Anti-Mullerian hormone level was slightly subnormal. Sperm cells were 3,900,000 per ejaculate. Histology of both testes showed spermatogonia, spermatocytes, and, in some tubes, matured spermatozoa. Sertoli cells were markedly stained with anti-inhibin alpha-subunit antibody in both the testes. There was no immunostaining of Sertoli, Leydig, or germ cells with anti-betaA or anti-betaB antibody. MAS R201H mutation was identified in both the testes.

CONCLUSION

The 15-year follow-up in this boy with MAS demonstrated that autonomous testicular activation and gonadotropin suppression persisted over time. This provides an interesting model of active spermatogenesis despite long-term FSH suppression. It also suggests that FSH is needed for the full expression of the inhibin betaB-subunit gene, an expression previously reported in the germ and Leydig cells of normal adult subjects.

[Importance of microlithiasis in testicular germ cell tumor ultrasound]

INTRODUCTION

Testicular microlithiasis (TM) is an infrequent finding in testicular ultrasound and its clinical importance has not been completely defined. We analyzed the ultrasounds of patients with testicular germ cell tumors in order to analyze the correlation between TM, histological findings and clinical variables.

METHODS AND MATERIALS

Fifty-seven patients with germ cell tumors and radical orchiectomy were included. Clinical, pathological, and echographic data were analyzed.

RESULTS

TM was observed in 27 men (48.27%) and was absent in 30 (52.6%). Patients with TM had a greater likelihood of nonseminomatous germ cell tumors (NSGCT) vs seminomatous (55.6% vs 30%, p=0.05), stage II/III testicular cancer (51.8% vs 16.7%, p=0.005), positive surgical margins (18.5% vs 0%, p=0.021), and spermatic cord invasion (14.8% vs 0%, p=0.048). No significant difference was found in respect to other histopathological variables.

CONCLUSION

This study showed that TM in testicular tumors is associated to NSGCT, advanced clinical stage, positive surgical margins, and spermatic cord invasion.

A non-endocrine cause of testicular enlargement mimicking precocious puberty: testicular microlithiasis

Untimely bilateral testicular enlargement greater than 3 ml is suggestive of precocious puberty, in which an underlying organic disease is more common in boys than in girls. We describe a 7 1/2 year-old boy presenting with testicular enlargement due to testicular microlithiasis. Following hormonal tests, diagnosis was based on ultrasonographic findings. Three years follow-up of the patient revealed normal pubertal progress and no malignant evolution. Testicular microlithiasis is a rare cause of testicular enlargement and pediatricians should take this disease into account in the differential diagnosis of suspected precocious puberty.

Intratesticular haematoma: differentiation from tumour on clinical history and ultrasound appearances in two cases

Intratesticular haematoma is not well described in the ultrasound literature and may be mistaken for a primary testicular malignancy if a detailed clinical history and careful ultrasound examination are not performed. We report two cases of intratesticular haematoma (one complicated by the presence of microlithiasis), describe the ultrasound appearances and document the natural history of the haematomas. A clinical history coupled with Doppler ultrasound features is crucial for conservative management.

Multi-cystic (rete testis) supernumerary testis in polyorchidism with underlying microlithiasis: Ultrasound features

Polyorchidism is a rare congenital anomaly, readily diagnosed on ultrasound. Testicular microlithiasis is a condition increasingly recognized and with a possible association with primary testicular malignancy. Rete testis has a variable appearance and is an unusual finding in the young patient. We describe the ultrasound appearances of the combination of polyorchidism, rete testis and microlithiasis, a combination that has not been previously reported.

US–MR Imaging Correlation in Pathologic Conditions of the Scrotum

Ultrasonography (US) is usually the initial imaging modality for evaluation of pathologic conditions of the scrotum. However, magnetic resonance (MR) imaging can be useful as a problem-solving tool when sonographic findings are equivocal. MR imaging allows characterization of scrotal masses as intratesticular or extratesticular and can demonstrate various types of lesions and tissue, including cysts or fluid, solid masses, fat, and fibrosis. MR imaging may be of value when the location of a scrotal mass is uncertain or when US does not allow differentiation between a solid mass and an inflammatory or vascular abnormality. Gadolinium-enhanced MR imaging can help differentiate between a benign cystic lesion and a cystic neoplasm. Gadolinium-enhanced imaging can also be used to demonstrate areas of absent or reduced testicular perfusion, such as in segmental testicular infarct. Finally, MR imaging can demonstrate an intraabdominal undescended testis, which can be difficult to detect with US, and is superior to US in differentiation between an undescended testis and testicular agenesis.

Testicular microlithiasis: our experience of 10 years

OBJECTIVE

Testicular microlithiasis (TM) is characterized on sonography by multiple microprecipitates in the testes. The correlation between TM and testicular malignancies is variable. The purpose of this study was to review our 10-year experience regarding the prevalence of TM and its association with testicular malignancies.

METHODS

This was a retrospective study in which 3254 testicular sonographic examinations over a 10-year period identified 137 patients with TM. Testicular microlithiasis was divided into 2 groups: classic TM (CTM; >or= 5 calcifications per image) and limited TM (<5 calcifications/image). A control population without TM was also randomly selected during the same period. Associations with testicular cancers and other findings were then noted and compared between the TM and control groups.

RESULTS

One hundred thirty-seven (4.6%) of the 2957 individual patients with scrotal sonographic examinations had TM; 8 (5.8%) of the 137 patients with TM had testicular cancer, whereas 1 (0.73%) of the 137 patients without TM had primary testicular cancer (P = .04). There were 9 testicular neoplasms in 8 patients, all of whom had CTM. Thirty patients with TM and no malignancy were followed for an average of 19 months (range, 1-90 months; SD, 19.7 months); none had tumor development.

CONCLUSIONS

We found a strong association between TM and testicular malignancy. We think that the most prudent use of resources for early detection of malignancy would be to have all patients with CTM perform testicular self-examinations, and follow-up sonography should be limited to a subgroup of patients with CTM and other associated risk factors.

Mutations in SLC34A2 cause pulmonary alveolar microlithiasis and are possibly associated with testicular microlithiasis

Pulmonary alveolar microlithiasis (PAM) is a rare disease characterized by the deposition of calcium phosphate microliths throughout the lungs. We first identified a PAM locus by homozygosity mapping to 4p15, then identified, by a candidate-gene approach, the gene responsible for the disease as SLC34A2 (the type IIb sodium-phosphate cotransporter gene), which is involved in phosphate homeostasis in several organs. We identified six homozygous exonic mutations in the seven unrelated patients with PAM we studied. Three of the mutations were frameshifts, one was a chain termination, one was an amino acid substitution, and one was a deletion spanning the minimal promoter and the first exon. Absence of functional protein product of the gene is compatible with calcium phosphate deposition in alveolar airspaces. We show that impaired activity of the phosphate transporter is presumably responsible for the microliths and that PAM is a recessive monogenic disease with full penetrance. Testicular microlithiasis (TM) is a disease that is more common than PAM. It is often associated with cancer and infertility. Since the gene we identified is also expressed in testis, we searched for mutations in subjects with TM. In 2 of the 15 subjects with TM we studied, we identified two rare variants, one synonymous and the other noncoding, that are possibly associated with the condition.

Association between testicular microlithiasis, testicular cancer, cryptorchidism and history of ascending testis

OBJECTIVE

To prospectively determine the prevalence of testicular microlithiasis in symptomatic patients who were referred for scrotal ultrasound examination and to evaluate the possible association of testicular microlithiasis with testicular cancer and other conditions such as cryptorchidism or history of ascending testis.

MATERIALS AND METHODS

391 men who were referred to our institutions between July 2002 and May 2005 for any type of symptoms from the testicles, underwent physical and scrotal ultrasound examination. The presence of testicular microlithiasis, the number of lesions and the involvement of both testicles in relation to the symptoms as well as the coexistence of other lesions were studied.

RESULTS

Eighteen (4.6%) of 391 men enrolled into the study had testicular microlithiasis. Two out of the eighteen patients (11%) had concomitant testicular cancer, which was confirmed by pathological evaluation of the orchidectomy specimen. One of the patients with testicular microlithiasis presented a rising in biochemical tumor markers (LDH, and HCG) and underwent orchidectomy one year later. Five of the remaining 373 (1.3%) patients without microlithiasis were diagnosed with testicular cancer. Thirty six men reported having a history of ascending testis, but none of them was found with testicular cancer. Two cases of testicular torsion in a cryptorchid position had testicular microlithiasis, but the orchidectomy specimen (after surgery) was negative for testicular cancer. The correlation between testicular cancer and testicular microlithiasis found in our study was statistically significant (p < 0.05).

CONCLUSION

There seems to be an association between testicular microlithiasis and testicular cancer.

Testicular calcification and microlithiasis: association with primary intra-testicular malignancy in 3,477 patients

The prevalence of all forms of scrotal and testicular calcification and their association with testicular tumour in a symptomatic paediatric and adult population was investigated. A retrospective study of all testicular ultrasound examinations performed at a single centre over a 5-year period was undertaken. All studies were performed by experienced operators, recorded in a standard method, using high-frequency linear array transducers (> or =10 MHz). All available images (95.2%) were reviewed by experienced operators, recording the location and type of scrotal and testicular calcification according to a pre-determined schedule. A total of 3,854 studies were reviewed on 3,477 patients (age range: 1 month to 91 years). In the adult group, 3,279 examinations were analysed. Prevalence of testicular microlithiasis (TM) was 2.0%, and the prevalence of other non-microlithiasis testicular calcification (non-TM calcification) was 1.7%. Testicular tumour was associated with TM (odds ratio 9.5, P<0.001) and non-TM calcification (odds ratio 11.4, P<0.001) but not with other types of scrotal calcification. A total of 198 paediatric examinations were analysed. Prevalence of TM was 2.0% and the prevalence of non-TM calcification was 0.5%. One tumour (lymphoma) was identified, with no associated calcification. This study confirms the reported association between TM and testicular tumour and finds a previously unreported association between non-TM calcification and testicular tumour.