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Case report: Paratesticular rhabdomyosarcoma — Colour Doppler appearances
130
CLINICAL RADIOLOGY
Clinical Radiology (1995) 50, 130-131
Case Report: Paratesticular RhabdomyosarcomaColour Doppler Appearances A. W O O D and K. C. D E W B U R Y
Department of Radiology, Southampton GeneralHospital, Southampton Paratesticular rhabdomyosarcoma is a rare tumour of childhood and early adult life. We report a case in which the paratesticular location and colour Doppler appearances led to confusion with epididymitis. W o o d , A. & Dcwbury, K.C. (1995). Clinical Radiology 50, 130 131. Case Report: Paratesticular R h a b d o m y o s a r c o m a - Colour Doppler Appearances
CASE R E P O R T A 17-year-old presented to his GP with a short history of a scrotal swelling. Ultrasound was performed using a 7.5 MHz linear probe: this showed a small highly reflective soft tissue mass in the epididymis, which showed increased vascularity on colour Doppler. The testis itself looked normal (Fig. 1). A diagnosis of epididymitis was made and the patient referred back to his GP for antibiotic therapy. Six months after the initial examination the patient was referred to a urologist since the scrotal swelling had slowly increased in size. A further US was performed with the same equipment which again showed a highly reflective mass attached to the edge of the testicle. Increased vascularity was again noted on colour Doppler (Fig. 2). There was now no discernible plane of cleavage between the mass and the testicle, which was swollen and showed decreased reflectivity. Ultrasound examination of the abdomen was normal. A diagnosis of scrotal malignancy was made. Inguinal orchidectomy was performed: histology showed a paratesticular rhabdomyosarcoma with spermatic cord margins free of turnout. Staging CT scan of chest, abdomen and pelvis, FBC, U § Es, LFTs, aFP and H C G were all normal: clinical and pathological staging were therefore confirmed as T1 NO M0. He is currently undergoing adjuvant chemotherapy with vincristine and actinomycin D.
~)
(a) (c) Correspondence to: Dr A. Wood, Department of Radiology, Southampton General Hospital, Tremona Road, Southampton SO9 4XY.
Fig. 1 (a) Initial presentation. Small highly reflective mass in epididymis (arrow). (b) Epididymal mass (straight arrow). Increased vascularity on colour Doppler. (c) Normal ipsilateral testicle.
CASE REPORTS
(a)
131
infrequent. Findings appear to be variable. The earliest report [4] described a hydrocoele and an echo-poor mass. Tannous et al. [5] illustrated their discussion of paratesticular rhabdomyosarcoma with an echo-poor mass. However, in another report [6], high reflectivity was noted in the epididymis in association with reduced reflectivity in the testicle. Freimanis et al. described a homogeneous echogenic appearance in a case of pleomorphic extratesticular myosarcoma [7]. Our case showed high reflectivity of the tumour, with subsequent development of reduced reflectivity within the testicle, perhaps due to oedema. The findings on colour Doppler examination have not previously been described. In our case a marked increase in vascularity was seen in the lesion on both occasions that it was examined. Hyperaemia is a well-recognized feature of scrotal inflammatory disease [8], and this and the extratesticular location of the lesion led to the initial diagnosis of epididymitis. However, neoplastic disease is also commonly hypervascular, especially in larger lesions [9]. On our second evaluation of this lesion the correct diagnosis was made, not least because the clinical features were such a strong indicator of a neoplastic process. Our case illustrates the limitations of testicular US. Previous reports have contrasted the high sensitivity of modern high-resolution US performed with a high frequency probe, with its lower specificity [10]. Differentiation of benign lesions from malignant can be difficult both in terms of grey-scale appearances and colour Doppler. There will always be some patients whose clinical presentation and ultrasonographic evaluation is sufficiently unusual as to lead to a delay in diagnosis.
REFERENCES
(b) Fig. 2 - (a) Six months later. Highly reflective epididymal mass (straight arrow). Indistinct plane of cleavage from testicle (curved arrow), which shows decreased reflectivity. (b) Epididymal mass (arrow) showing markedly increased vascularity on colour Doppler.
DISCUSSION Paratesticular rhabdomyosarcoma comprises approximately 4% of all rhabdomyosarcomas in children [1]. These are rare tumours with approximately 50 new cases occurring annually in children under 15 in England, Scotland and Wales [2]. Patients with disease localized to the scrotum have a good prognosis [1,3]. Descriptions of the find!ngs on US examination are
1 Hamilton CR, Pinkerton R, Horwich A. The management of paratesticular rhabdomyosarcoma. Clinical Radiology 1989;40: 314-317. 2 Kingston JE, McElwain T J, Malpas JS. Childhood rhabdomyosarcoma: experience of the Children's Solid Tumour Group. British Journal of Cancer 1983;48:195-207. 3 Raney RB, Teffet M, Lawrence W e t al. Paratesticular sarcoma in childhood and adolescence. Cancer 1987;60:2337. 4 Solvietti FB, D'Ascenzo R, Molisso A et al. Rhabdomyosarcoma of the funiculus. Journal of Clinical Ultrasound 1989; 17:521- 522. 5 Tannous WN, Azouz EM, Homsy YL et al. CT and ultrasound of pelvic rhabdomyosarcoma in children. Pediatric Radiology 1989; 19:530-534. 6 Goff WB, Lawrence DP, Deweese RA. Rhabdomyosarcoma of the testicular appendage in an infant: Case report. Clinical Pediatrics 1990;29:412-413. 7 Freimanis MG, Bohm-Velez M, Mendelson EB et al. Ultrasound appearance of extratesticular myosarcoma. Journal of Clinical Ultrasound 1991;19:101-104. 8 Horstman WG, Middleton WD, Leland Melson G. Scrotal inflammatory disease: color Doppler US findings. Radiology 1991;179:5559. 9 Horstman WG, Leland Melson G, Middleton WD et al. Testicular tumors: findings with color Doppler US. Radiology 1992;185:733737. 10 Fowler R. Imaging the testis and scrotal structures. Clinical Radiology 1990;41:81-85.
CLINICAL RADIOLOGY
Clinical Radiology (1995) 50, 130-131
Case Report: Paratesticular RhabdomyosarcomaColour Doppler Appearances A. W O O D and K. C. D E W B U R Y
Department of Radiology, Southampton GeneralHospital, Southampton Paratesticular rhabdomyosarcoma is a rare tumour of childhood and early adult life. We report a case in which the paratesticular location and colour Doppler appearances led to confusion with epididymitis. W o o d , A. & Dcwbury, K.C. (1995). Clinical Radiology 50, 130 131. Case Report: Paratesticular R h a b d o m y o s a r c o m a - Colour Doppler Appearances
CASE R E P O R T A 17-year-old presented to his GP with a short history of a scrotal swelling. Ultrasound was performed using a 7.5 MHz linear probe: this showed a small highly reflective soft tissue mass in the epididymis, which showed increased vascularity on colour Doppler. The testis itself looked normal (Fig. 1). A diagnosis of epididymitis was made and the patient referred back to his GP for antibiotic therapy. Six months after the initial examination the patient was referred to a urologist since the scrotal swelling had slowly increased in size. A further US was performed with the same equipment which again showed a highly reflective mass attached to the edge of the testicle. Increased vascularity was again noted on colour Doppler (Fig. 2). There was now no discernible plane of cleavage between the mass and the testicle, which was swollen and showed decreased reflectivity. Ultrasound examination of the abdomen was normal. A diagnosis of scrotal malignancy was made. Inguinal orchidectomy was performed: histology showed a paratesticular rhabdomyosarcoma with spermatic cord margins free of turnout. Staging CT scan of chest, abdomen and pelvis, FBC, U § Es, LFTs, aFP and H C G were all normal: clinical and pathological staging were therefore confirmed as T1 NO M0. He is currently undergoing adjuvant chemotherapy with vincristine and actinomycin D.
~)
(a) (c) Correspondence to: Dr A. Wood, Department of Radiology, Southampton General Hospital, Tremona Road, Southampton SO9 4XY.
Fig. 1 (a) Initial presentation. Small highly reflective mass in epididymis (arrow). (b) Epididymal mass (straight arrow). Increased vascularity on colour Doppler. (c) Normal ipsilateral testicle.
CASE REPORTS
(a)
131
infrequent. Findings appear to be variable. The earliest report [4] described a hydrocoele and an echo-poor mass. Tannous et al. [5] illustrated their discussion of paratesticular rhabdomyosarcoma with an echo-poor mass. However, in another report [6], high reflectivity was noted in the epididymis in association with reduced reflectivity in the testicle. Freimanis et al. described a homogeneous echogenic appearance in a case of pleomorphic extratesticular myosarcoma [7]. Our case showed high reflectivity of the tumour, with subsequent development of reduced reflectivity within the testicle, perhaps due to oedema. The findings on colour Doppler examination have not previously been described. In our case a marked increase in vascularity was seen in the lesion on both occasions that it was examined. Hyperaemia is a well-recognized feature of scrotal inflammatory disease [8], and this and the extratesticular location of the lesion led to the initial diagnosis of epididymitis. However, neoplastic disease is also commonly hypervascular, especially in larger lesions [9]. On our second evaluation of this lesion the correct diagnosis was made, not least because the clinical features were such a strong indicator of a neoplastic process. Our case illustrates the limitations of testicular US. Previous reports have contrasted the high sensitivity of modern high-resolution US performed with a high frequency probe, with its lower specificity [10]. Differentiation of benign lesions from malignant can be difficult both in terms of grey-scale appearances and colour Doppler. There will always be some patients whose clinical presentation and ultrasonographic evaluation is sufficiently unusual as to lead to a delay in diagnosis.
REFERENCES
(b) Fig. 2 - (a) Six months later. Highly reflective epididymal mass (straight arrow). Indistinct plane of cleavage from testicle (curved arrow), which shows decreased reflectivity. (b) Epididymal mass (arrow) showing markedly increased vascularity on colour Doppler.
DISCUSSION Paratesticular rhabdomyosarcoma comprises approximately 4% of all rhabdomyosarcomas in children [1]. These are rare tumours with approximately 50 new cases occurring annually in children under 15 in England, Scotland and Wales [2]. Patients with disease localized to the scrotum have a good prognosis [1,3]. Descriptions of the find!ngs on US examination are
1 Hamilton CR, Pinkerton R, Horwich A. The management of paratesticular rhabdomyosarcoma. Clinical Radiology 1989;40: 314-317. 2 Kingston JE, McElwain T J, Malpas JS. Childhood rhabdomyosarcoma: experience of the Children's Solid Tumour Group. British Journal of Cancer 1983;48:195-207. 3 Raney RB, Teffet M, Lawrence W e t al. Paratesticular sarcoma in childhood and adolescence. Cancer 1987;60:2337. 4 Solvietti FB, D'Ascenzo R, Molisso A et al. Rhabdomyosarcoma of the funiculus. Journal of Clinical Ultrasound 1989; 17:521- 522. 5 Tannous WN, Azouz EM, Homsy YL et al. CT and ultrasound of pelvic rhabdomyosarcoma in children. Pediatric Radiology 1989; 19:530-534. 6 Goff WB, Lawrence DP, Deweese RA. Rhabdomyosarcoma of the testicular appendage in an infant: Case report. Clinical Pediatrics 1990;29:412-413. 7 Freimanis MG, Bohm-Velez M, Mendelson EB et al. Ultrasound appearance of extratesticular myosarcoma. Journal of Clinical Ultrasound 1991;19:101-104. 8 Horstman WG, Middleton WD, Leland Melson G. Scrotal inflammatory disease: color Doppler US findings. Radiology 1991;179:5559. 9 Horstman WG, Leland Melson G, Middleton WD et al. Testicular tumors: findings with color Doppler US. Radiology 1992;185:733737. 10 Fowler R. Imaging the testis and scrotal structures. Clinical Radiology 1990;41:81-85.