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Adenomatoid Tumor of Testicular Tunica Albuginea Mimicking Testicular Carcinoma
0022-5347/88/1394-0819$2.00/0 Vol. 139, April Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1988 by The Williams & Wilkins Co.
ADENOMATOID TUMOR OF TESTICULAR TUNICA ALBUGINEA MIMICKING TESTICULAR CARCINOMA ALAN L. MANSON* From the Department of Urology, Naval Hospital, Great Lakes, Illinois
ABSTRACT
Adenomatoid tumors are an uncommon neoplasm of the paratesticular tissues, with the majority of the reported cases involving the epididymis. A case is reported of an adenomatoid tumor of the testicular tunica albuginea that masqueraded as testicular carcinoma. (J. Urol., 139: 819-820, 1988) The adenomatoid tumor is a well recognized neoplasm that primarily is found in the paratesticular tissues of the male subject, and the uterus and fallopian tubes in the female subject.1 The overwhelming majority of these tumors present within the epididymis and only rare cases have been reported of tumors involving the spermatic cord, testicular tunics, ejaculatory ducts or prostate.1-3 Since these tumors are considered benign, the major clinical significance lies in the inability preoperatively to exclude definitively other malignant lesions. A case is reported of an adenomatoid tumor that clinically mimicked testicular carcinoma. CASE REPORT
A 32-year-old white man underwent a routine physical examination and a firm nodule of the left testis was noted. Subsequent urological examination demonstrated a 1.5 cm. hard fixed nodule of the anterior testicular surface, which did not transmit light. The epididymis and spermatic cord were well separated from the lesion. Testicular ultrasound revealed mild irregularity of the anterior surface but an intraparenchymal mass could not be identified (fig. 1). Owing to the highly suspicious physical findings, left inguinal exploration was performed. After vascular clamping of the spermatic cord at the internal ring the testis was produced through the wound and examined. A firm, poorly defined area of focal induration was identified on the anterior surface of the testicular tunica albuginea. The surgeon's impression was that it represented a tunical scar or fibrous plaque from an old injury or prior inflammatory process. The lesion was excised and sent for frozen section. The underlying testicular parenchyma appeared to be grossly normal. The pathological interpretation of the frozen section indicated that it was not a testicular germ cell tumor, although a neoplastic process could not be ruled out, and the final diagnosis was deferred pending review of the permanent section. A standard inguinal orchiectomy then was performed. Convalescence was uneventful. Final pathological evaluation revealed a 1.2 X 0.9 X 0.3 cm. whitish plaque that only involved the tunica albuginea. There was no invasion or involvement of the underlying testicular paranchyma or paratesticular structures. Histological examination demonstrated areas of focal fibrous thickening associated with a typical adenomatoid tumor (fig. 2). The neoplasm was composed of benign-appearing cells arranged in small glands and cords. The cells varied in shape from flattened to cuboidal and the cytoplasm was occasionally vacuolated. The nuclei were round to oval with diffuse chromatin. The diagnosis of adenomatoid tumor was confirmed on consultation with the Armed Forces Institute of Pathology. Accepted for publication July 10, 1987. The views expressed herein are those of the author and do not necessarily reflect the views of the United States Navy or the Department of Defense. * Current address: Department of Urology, Naval Hospital, Oakland, California 94627.
DISCUSSION
Since the original conception of the term "adenomatoid tumor" by Golden and Ash in 1945,4 it has become well recognized as the most common paratesticular tumor. 1 The majority of cases appear adjacent to or within the epididymis and most often they present in the lower pole. 5 • 6 They typically present as small firm asymptomatic intrascrotal masses. Rare case reports exist of involvement with the spermatic cord, testicular tunics, ejaculatory ducts or prostate.1-3 Although a malignant form of adenomatoid tumor has been reported7 most authorities consider it to be a benign process. 1 The possible histogenesis of this tumor has produced controversy during the years. Although some data are contradictory most recent studies have confumed the mesothelial origin of the adenomatoid tumor.S-10 Studies have demonstrated the presence of cytoplasmic keratin, and the absence of carcinoembryonic antigen and factor VIII-related antigen in these tumors. Studies using an indirect immunoperoxidase technique also have verified the presence of mesothelial antigen confirming its mesothelial origin. 8 Since these tumors usually are small, asymptomatic and benign in nature, 1·5 • 6 their primary clinical significance lies in the difficulty in excluding other malignant lesions preoperatively. An adenomatoid tumor may be suspected strongly in the evaluation of a solid epididymal mass, since it represents the most common neoplasm involving the epididymis.5 • 6 In these cases surgical excision or epididymectomy is adequate for diagnosis and treatment. However, confusion may result when a
FIG. 1. Left testicular ultrasound demonstrates absence of intraparenchymal mass. 819
820
MANSON
FIG. 2. Adenomatoid tumor of testicular tunica albuginea. A, reduced from XlOO. B, reduced from X400
rare adenomatoid tumor presents on the testicular tunica albuginea. Preoperative ultrasound may offer a clue as to the superficial nature of the lesion, which would be verified at intraoperative examination. However, it is mandatory to obtain a definite diagnosis from the frozen section before unclamping the spermatic cord and returning the testis to the scrotum. Therefore, it is essential that the urologist notify the pathologist to consider the possibility of an adenomatoid tumor in the differential diagnosis of any lesion that appears to originate from the testicular tunics or paratesticular structures. Failure to consider this diagnosis may result in needless orchiectomy. REFERENCES
1. Mostofi, F. K. and Price, E. B., Jr.: Tumors of the male genital system. In: Atlas of Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, 2nd series, fasc. 8, pp. 144-151, 1973. 2. Fan, K. and Johnson, D. F.: Adenomatoid tumor of ejaculatory duct. Urology, 25: 653, 1985. 3. Chen, K. T. and Schiff, J. T.: Adenomatoid prostatic tumor. Urol-
ogy, 21: 88, 1983. 4. Golden, A. and Ash, J.E.: Adenomatoid tumor of the genital tract. Amer. J. Path., 21: 63, 1945. 5. Longo, V. J., McDonald, J. R. and Thompson, G. J.: Primary neoplasms of the epididymis: special reference to adenomatoid tumors. J.A.M.A., 147: 937, 1951. 6. Broth, G., Bullock, W. K. and Morrow, J.: Epididymal tumors: 1. Report of 15 new cases including review of literature. 2. Histochemical study of the so-called adenomatoid tumor. J. Urol., 100: 530, 1968. 7. Soderstrom, J. and Liedberg, C. F.: Malignant "adenomatoid" tumour of the epididymis. Acta Path. Microbiol. Scand., 67: 165, 1966. 8. Mucientes, F., Govindarajan, S. and Burotto, S.: Immunoperoxidase study on adenomatoid tumor of the epididymis using antimesothelial cell serum. Cancer, 55: 363, 1985. 9. Barwick, K. W. and Madri, J. A.: A immunohistochemical study of adenomatoid tumors utilizing keratin and factor VIII antibodies. Evidence for a mesothelial origin. Lab. Invest., 47: 276, 1982. 10. Said, J. W., Nash, G. and Lee, M.: Immunoperoxidase localization of keratin proteins, carcinoembryonic antigen, and factor VIII in adenomatoid tumors: evidence for a mesothelial derivation. Hum. Path., 13: 1106, 1982.
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THE JOURNAL OF UROLOGY
Copyright© 1988 by The Williams & Wilkins Co.
ADENOMATOID TUMOR OF TESTICULAR TUNICA ALBUGINEA MIMICKING TESTICULAR CARCINOMA ALAN L. MANSON* From the Department of Urology, Naval Hospital, Great Lakes, Illinois
ABSTRACT
Adenomatoid tumors are an uncommon neoplasm of the paratesticular tissues, with the majority of the reported cases involving the epididymis. A case is reported of an adenomatoid tumor of the testicular tunica albuginea that masqueraded as testicular carcinoma. (J. Urol., 139: 819-820, 1988) The adenomatoid tumor is a well recognized neoplasm that primarily is found in the paratesticular tissues of the male subject, and the uterus and fallopian tubes in the female subject.1 The overwhelming majority of these tumors present within the epididymis and only rare cases have been reported of tumors involving the spermatic cord, testicular tunics, ejaculatory ducts or prostate.1-3 Since these tumors are considered benign, the major clinical significance lies in the inability preoperatively to exclude definitively other malignant lesions. A case is reported of an adenomatoid tumor that clinically mimicked testicular carcinoma. CASE REPORT
A 32-year-old white man underwent a routine physical examination and a firm nodule of the left testis was noted. Subsequent urological examination demonstrated a 1.5 cm. hard fixed nodule of the anterior testicular surface, which did not transmit light. The epididymis and spermatic cord were well separated from the lesion. Testicular ultrasound revealed mild irregularity of the anterior surface but an intraparenchymal mass could not be identified (fig. 1). Owing to the highly suspicious physical findings, left inguinal exploration was performed. After vascular clamping of the spermatic cord at the internal ring the testis was produced through the wound and examined. A firm, poorly defined area of focal induration was identified on the anterior surface of the testicular tunica albuginea. The surgeon's impression was that it represented a tunical scar or fibrous plaque from an old injury or prior inflammatory process. The lesion was excised and sent for frozen section. The underlying testicular parenchyma appeared to be grossly normal. The pathological interpretation of the frozen section indicated that it was not a testicular germ cell tumor, although a neoplastic process could not be ruled out, and the final diagnosis was deferred pending review of the permanent section. A standard inguinal orchiectomy then was performed. Convalescence was uneventful. Final pathological evaluation revealed a 1.2 X 0.9 X 0.3 cm. whitish plaque that only involved the tunica albuginea. There was no invasion or involvement of the underlying testicular paranchyma or paratesticular structures. Histological examination demonstrated areas of focal fibrous thickening associated with a typical adenomatoid tumor (fig. 2). The neoplasm was composed of benign-appearing cells arranged in small glands and cords. The cells varied in shape from flattened to cuboidal and the cytoplasm was occasionally vacuolated. The nuclei were round to oval with diffuse chromatin. The diagnosis of adenomatoid tumor was confirmed on consultation with the Armed Forces Institute of Pathology. Accepted for publication July 10, 1987. The views expressed herein are those of the author and do not necessarily reflect the views of the United States Navy or the Department of Defense. * Current address: Department of Urology, Naval Hospital, Oakland, California 94627.
DISCUSSION
Since the original conception of the term "adenomatoid tumor" by Golden and Ash in 1945,4 it has become well recognized as the most common paratesticular tumor. 1 The majority of cases appear adjacent to or within the epididymis and most often they present in the lower pole. 5 • 6 They typically present as small firm asymptomatic intrascrotal masses. Rare case reports exist of involvement with the spermatic cord, testicular tunics, ejaculatory ducts or prostate.1-3 Although a malignant form of adenomatoid tumor has been reported7 most authorities consider it to be a benign process. 1 The possible histogenesis of this tumor has produced controversy during the years. Although some data are contradictory most recent studies have confumed the mesothelial origin of the adenomatoid tumor.S-10 Studies have demonstrated the presence of cytoplasmic keratin, and the absence of carcinoembryonic antigen and factor VIII-related antigen in these tumors. Studies using an indirect immunoperoxidase technique also have verified the presence of mesothelial antigen confirming its mesothelial origin. 8 Since these tumors usually are small, asymptomatic and benign in nature, 1·5 • 6 their primary clinical significance lies in the difficulty in excluding other malignant lesions preoperatively. An adenomatoid tumor may be suspected strongly in the evaluation of a solid epididymal mass, since it represents the most common neoplasm involving the epididymis.5 • 6 In these cases surgical excision or epididymectomy is adequate for diagnosis and treatment. However, confusion may result when a
FIG. 1. Left testicular ultrasound demonstrates absence of intraparenchymal mass. 819
820
MANSON
FIG. 2. Adenomatoid tumor of testicular tunica albuginea. A, reduced from XlOO. B, reduced from X400
rare adenomatoid tumor presents on the testicular tunica albuginea. Preoperative ultrasound may offer a clue as to the superficial nature of the lesion, which would be verified at intraoperative examination. However, it is mandatory to obtain a definite diagnosis from the frozen section before unclamping the spermatic cord and returning the testis to the scrotum. Therefore, it is essential that the urologist notify the pathologist to consider the possibility of an adenomatoid tumor in the differential diagnosis of any lesion that appears to originate from the testicular tunics or paratesticular structures. Failure to consider this diagnosis may result in needless orchiectomy. REFERENCES
1. Mostofi, F. K. and Price, E. B., Jr.: Tumors of the male genital system. In: Atlas of Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, 2nd series, fasc. 8, pp. 144-151, 1973. 2. Fan, K. and Johnson, D. F.: Adenomatoid tumor of ejaculatory duct. Urology, 25: 653, 1985. 3. Chen, K. T. and Schiff, J. T.: Adenomatoid prostatic tumor. Urol-
ogy, 21: 88, 1983. 4. Golden, A. and Ash, J.E.: Adenomatoid tumor of the genital tract. Amer. J. Path., 21: 63, 1945. 5. Longo, V. J., McDonald, J. R. and Thompson, G. J.: Primary neoplasms of the epididymis: special reference to adenomatoid tumors. J.A.M.A., 147: 937, 1951. 6. Broth, G., Bullock, W. K. and Morrow, J.: Epididymal tumors: 1. Report of 15 new cases including review of literature. 2. Histochemical study of the so-called adenomatoid tumor. J. Urol., 100: 530, 1968. 7. Soderstrom, J. and Liedberg, C. F.: Malignant "adenomatoid" tumour of the epididymis. Acta Path. Microbiol. Scand., 67: 165, 1966. 8. Mucientes, F., Govindarajan, S. and Burotto, S.: Immunoperoxidase study on adenomatoid tumor of the epididymis using antimesothelial cell serum. Cancer, 55: 363, 1985. 9. Barwick, K. W. and Madri, J. A.: A immunohistochemical study of adenomatoid tumors utilizing keratin and factor VIII antibodies. Evidence for a mesothelial origin. Lab. Invest., 47: 276, 1982. 10. Said, J. W., Nash, G. and Lee, M.: Immunoperoxidase localization of keratin proteins, carcinoembryonic antigen, and factor VIII in adenomatoid tumors: evidence for a mesothelial derivation. Hum. Path., 13: 1106, 1982.
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