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Painless scrotal mass in a child
Radiologic-Pathologic Correlation Arvin E. Robinson, MD, Editor
Painless Scrotal Mass in a Child David R. Feldman, MD, Nancy S. Curry, MD, Denise Mulvihill, MD, Paul Gelven, MD
CLINICAL PRESENTATION
PATHOLOGIC FINDINGS
The parents of a 15-month-old white male child incidentally discovered a painless mass in the left scrotal sac. Physical examination confirmed this finding, absence of inguinal lymphadenopathy, and presence of a normal right scrotal sac and contents.
Gross pathologic examination demonstrated a wellcircumscribed tan-yellow mass virtually replacing the left testicle. Components of ectodermal tissue (some neuroepithelial foci and dermal appendages), endodermal tissue (respiratory epithelium), and mesodermal tissue (cartilage with foci of ossification) were microscopically intermixed along with scattered rests of normal seminiferous tubules and testicular interstitium (Fig. 2). There was no histologic immaturity. Neither mitotic figures nor foci of embryonal or extraembryonic carcinoma were present.
RADIOLOGIC PRESENTATION
Ultrasound examination demonstrated a heterogeneous 2.5 x 2.5 cm well-circumscribed mass replacing the left testicle. The adjacent epididymis was uninvolved, and there was no associated hydrocele. The lesion contained areas of increased echogenicity with acoustical shadowing typical of calcification as well as discrete anechoic areas with backwall enhancement suggesting admixed cystic c o m p o n e n t s (Fig. 1). Doppler examination of the vascular pedicle demonstrated a patent testicular artery and patent draining veins, each with appropriate flow signal. RADIOLOGIC DIAGNOSIS
The diagnosis was testicular teratoma. CLINICAL COURSE
Based on physical and ultrasound examination, the patient underwent left inguinal exploration and radical orchiectomy. The lesion was completely excised and the patient had an uneventful recovery.
CLINICAL DIAGNOSIS
The clinical diagnosis was benign testicular teratoma. DISCUSSION
Painless scrotal masses in children usually represent benign disease of the testis or extratesticular structures, typically manifest as a cystic process. Solid lesions are more likely to represent a malignant process, although testicular neoplasms are u n c o m m o n in children [1]. They are usually detected by age 3 [2] and are usually of germ cell origin. In childhood, the most c o m m o n malignant testicular tumor is endodermal sinus carcinoma, whereas the most c o m m o n benign germinal tumor is teratoma [3]. In the largest recent series of pediatric teratomas (245 patients with 254 teratomas), 3% were testicular lesions
From the Departmentsof Radiology and Pathology, Medical Universityof South Carolina, Charleston, SC. Address reprint requestto N. S. Curry, MD, Departmentof Radiology, Medical Universityof SouthCarolina,171 AshleyAve., Charleston,SC 29425. Received June20, 1994,and acceptedfor publicationafter revisionJuly 20, 1994. Acad Radio11995;2:260-262 © 1995, Association of University Radiologists
260
Vol. 2, No. 3,°March 1995
A
PAINLESS
B
SCROTAL
MASS
IN C H I L D
C
FIGURE 1. ,4, Transverse sonogram demonstrates heterogeneous lesion of left hemiscrotum containing cystic areas admixed with loci of increased echogenicity and acoustical shadowing. B, Longitudinal sonogram of left testicle demonstrates virtual replacement of entire testis by heterogeneous mass. C, Longitudinal sonogram of normal right testis. RT = right testicle, LT = left testicle.
A
B
C
FIGURE 2. A, Photomicrograph demonstrates neuroectodermal tissue with histologically mature features (X300). B, Mesodermal derivatives represented in tumor as mature-appearing cartilage (X300). C, Endodermal component represented as glandular epithelium surrounded by compressed normal seminiferoustubules (X30).
with a mean patient age of 41 months [4]. Testicular teraroma displays a bimodal age distribution occurring more commonly in infancy or early childhood and again after puberty [5] and represents about 30% of all childhood testicular neoplasms. Teratomas are tumors comprised of tissue not normally found at their site of origin. They are believed to arise from totipotential germ cells. These totipotential cells may differentiate into a more mature histopathologic stage (embryonal carcinoma) or further differentiate into either an extraembryonic neoplasm (endodermal sinus tumor or
choriocarcinoma) or an embryonic neoplasm (teratoma) [5]. Although teratomas classically contain all three germ cells layers (endoderm, mesoderm, and ectoderm), recent relaxation of this definition has allowed inclusion of neoplasms with only two germ cell types. Grossly, these lesions tend to be well circumscribed and have a variegated appearance on a cut surface reflecting the diversity of tissue elements [4]. Necrosis or visible hemorrhage is an unusual feature even in poorly differentiated lesions. Microscopically, all three germ cells lines may be represented in variable amounts in as many as 90% of
261
FELDMAN
E T AL.
cases [4]. The histologic grade of maturity can be assessed by sampling at least one section per 1-2 cm of tumor [4]. The World Health Organization classification of teratomas divides them into groups by presence of mature, immature, or frankly malignant elements [5]. About half of pediatric teratomas contain immature elements [6, 7], but in younger children biologic behavior of these neoplasms is benign [5] and approximates that of mature lesions in older patients. Histologic grade of a teratoma is determined in part by amount of primitive neuroepithelial tissue present [4]. Even malignant testicular teratomas in children have a good prognosis, particularly compared with malignant teratomas in other sites, and in some cases may be treated by surgical resection alone [8]. Ultrasound is an ideal imaging modality for evaluating scrotal masses because it is safe, rapid, and easy to perform and can immediately determine essential features of intrascrotal pathology (cystic vs solid, testicular vs extratesticular). Sonographic findings indicating teratoma include intratesticular location, heterogeneous echotexture, and frequency of cystic components. Although not universally present, focal areas of increased echogenicity with shadowing suggestive of ossification or calcification strongly support the diagnosis [9]. Differential diagnosis of a solid testicular lesion in a child should include other primary malignancies such as an extraembryonic germ cell tumor, which should not demonstrate cystic areas, calcification, or ossification [9]. Secondary tumors such as leukemia or lym-
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Vol. 2, No. 3, March 1995
phoma would image similarly. Non-germ-cell primary tumors of the testis are more common in children than adults [1] and m'e usually Leydig or Sertoli cell tumors [10]. Teratomas of the testis in infants and children impart a good prognosis. They rarely metastasize in this age group [11] and are usually cured by resection w h e n localized to the testis [5]. Patients with nonresectable or metastatic disease may be offered adjuvant radiotherapy or chemotherapy, which have demonstrated effectiveness in small patients series [8, 12]. REFERENCES 1, Hopkins T, Jaffe N, Colodny A, et al. The management of testicular tumors in children. J Uro11978;120:96-102. 2. Bhargava M, Reddy D. Tumors of the testis. Cancer1966;19:1655-1665. 3, Exelby P. Testis cancer in children. Semin Onco11979;6:116-120. 4, Tapper D, Lack E. Teratomas in infancy and childhood. Ann Surg 1983; 198(3):398-410. 5. Hudson M, Konvolinka C, Deshmukh N. High-grade immature teratoma of the testis in infancy. Mil Med 1992;157(9):501-4. 6. Carney J, Thompson D, Johnson C, et al. Teratomas in children: clinical and pathological aspects. J Pediatr Surg 1972;7:271-282. 7, Mahour G, Woolley M, Trivedi $, et al. Teratomas in infancy and childhood. Surgery 1974;76:309-318. 8, Billmire D, Grosfeld J. Teratomas in childhood: analysis of 142 cases. J Pediatr Surg 1988;21:548-551. 9. Liu P, Phillips M, Edwards V, et al. Sonographic findings of testicular teratoma with pathologic correlation. Pediatr Radio11992;22:99-101. 10. Barth R, Teele R, Colodny A, et al. Asymptomatic sorotal masses in child ren. Radiology 1984; 152:65-68. 11. Mostofi F, Price E. Tumors of the male genital system: atlas of tumor pathology. Washington, DC: Armed Forces Institute of Pathology, 1973:59. 12, Green D. The diagnosis and treatment of yolk sac tumors in infants and children. Cancer Treat Rev 1983; 10:265-288.
Painless Scrotal Mass in a Child David R. Feldman, MD, Nancy S. Curry, MD, Denise Mulvihill, MD, Paul Gelven, MD
CLINICAL PRESENTATION
PATHOLOGIC FINDINGS
The parents of a 15-month-old white male child incidentally discovered a painless mass in the left scrotal sac. Physical examination confirmed this finding, absence of inguinal lymphadenopathy, and presence of a normal right scrotal sac and contents.
Gross pathologic examination demonstrated a wellcircumscribed tan-yellow mass virtually replacing the left testicle. Components of ectodermal tissue (some neuroepithelial foci and dermal appendages), endodermal tissue (respiratory epithelium), and mesodermal tissue (cartilage with foci of ossification) were microscopically intermixed along with scattered rests of normal seminiferous tubules and testicular interstitium (Fig. 2). There was no histologic immaturity. Neither mitotic figures nor foci of embryonal or extraembryonic carcinoma were present.
RADIOLOGIC PRESENTATION
Ultrasound examination demonstrated a heterogeneous 2.5 x 2.5 cm well-circumscribed mass replacing the left testicle. The adjacent epididymis was uninvolved, and there was no associated hydrocele. The lesion contained areas of increased echogenicity with acoustical shadowing typical of calcification as well as discrete anechoic areas with backwall enhancement suggesting admixed cystic c o m p o n e n t s (Fig. 1). Doppler examination of the vascular pedicle demonstrated a patent testicular artery and patent draining veins, each with appropriate flow signal. RADIOLOGIC DIAGNOSIS
The diagnosis was testicular teratoma. CLINICAL COURSE
Based on physical and ultrasound examination, the patient underwent left inguinal exploration and radical orchiectomy. The lesion was completely excised and the patient had an uneventful recovery.
CLINICAL DIAGNOSIS
The clinical diagnosis was benign testicular teratoma. DISCUSSION
Painless scrotal masses in children usually represent benign disease of the testis or extratesticular structures, typically manifest as a cystic process. Solid lesions are more likely to represent a malignant process, although testicular neoplasms are u n c o m m o n in children [1]. They are usually detected by age 3 [2] and are usually of germ cell origin. In childhood, the most c o m m o n malignant testicular tumor is endodermal sinus carcinoma, whereas the most c o m m o n benign germinal tumor is teratoma [3]. In the largest recent series of pediatric teratomas (245 patients with 254 teratomas), 3% were testicular lesions
From the Departmentsof Radiology and Pathology, Medical Universityof South Carolina, Charleston, SC. Address reprint requestto N. S. Curry, MD, Departmentof Radiology, Medical Universityof SouthCarolina,171 AshleyAve., Charleston,SC 29425. Received June20, 1994,and acceptedfor publicationafter revisionJuly 20, 1994. Acad Radio11995;2:260-262 © 1995, Association of University Radiologists
260
Vol. 2, No. 3,°March 1995
A
PAINLESS
B
SCROTAL
MASS
IN C H I L D
C
FIGURE 1. ,4, Transverse sonogram demonstrates heterogeneous lesion of left hemiscrotum containing cystic areas admixed with loci of increased echogenicity and acoustical shadowing. B, Longitudinal sonogram of left testicle demonstrates virtual replacement of entire testis by heterogeneous mass. C, Longitudinal sonogram of normal right testis. RT = right testicle, LT = left testicle.
A
B
C
FIGURE 2. A, Photomicrograph demonstrates neuroectodermal tissue with histologically mature features (X300). B, Mesodermal derivatives represented in tumor as mature-appearing cartilage (X300). C, Endodermal component represented as glandular epithelium surrounded by compressed normal seminiferoustubules (X30).
with a mean patient age of 41 months [4]. Testicular teraroma displays a bimodal age distribution occurring more commonly in infancy or early childhood and again after puberty [5] and represents about 30% of all childhood testicular neoplasms. Teratomas are tumors comprised of tissue not normally found at their site of origin. They are believed to arise from totipotential germ cells. These totipotential cells may differentiate into a more mature histopathologic stage (embryonal carcinoma) or further differentiate into either an extraembryonic neoplasm (endodermal sinus tumor or
choriocarcinoma) or an embryonic neoplasm (teratoma) [5]. Although teratomas classically contain all three germ cells layers (endoderm, mesoderm, and ectoderm), recent relaxation of this definition has allowed inclusion of neoplasms with only two germ cell types. Grossly, these lesions tend to be well circumscribed and have a variegated appearance on a cut surface reflecting the diversity of tissue elements [4]. Necrosis or visible hemorrhage is an unusual feature even in poorly differentiated lesions. Microscopically, all three germ cells lines may be represented in variable amounts in as many as 90% of
261
FELDMAN
E T AL.
cases [4]. The histologic grade of maturity can be assessed by sampling at least one section per 1-2 cm of tumor [4]. The World Health Organization classification of teratomas divides them into groups by presence of mature, immature, or frankly malignant elements [5]. About half of pediatric teratomas contain immature elements [6, 7], but in younger children biologic behavior of these neoplasms is benign [5] and approximates that of mature lesions in older patients. Histologic grade of a teratoma is determined in part by amount of primitive neuroepithelial tissue present [4]. Even malignant testicular teratomas in children have a good prognosis, particularly compared with malignant teratomas in other sites, and in some cases may be treated by surgical resection alone [8]. Ultrasound is an ideal imaging modality for evaluating scrotal masses because it is safe, rapid, and easy to perform and can immediately determine essential features of intrascrotal pathology (cystic vs solid, testicular vs extratesticular). Sonographic findings indicating teratoma include intratesticular location, heterogeneous echotexture, and frequency of cystic components. Although not universally present, focal areas of increased echogenicity with shadowing suggestive of ossification or calcification strongly support the diagnosis [9]. Differential diagnosis of a solid testicular lesion in a child should include other primary malignancies such as an extraembryonic germ cell tumor, which should not demonstrate cystic areas, calcification, or ossification [9]. Secondary tumors such as leukemia or lym-
262
Vol. 2, No. 3, March 1995
phoma would image similarly. Non-germ-cell primary tumors of the testis are more common in children than adults [1] and m'e usually Leydig or Sertoli cell tumors [10]. Teratomas of the testis in infants and children impart a good prognosis. They rarely metastasize in this age group [11] and are usually cured by resection w h e n localized to the testis [5]. Patients with nonresectable or metastatic disease may be offered adjuvant radiotherapy or chemotherapy, which have demonstrated effectiveness in small patients series [8, 12]. REFERENCES 1, Hopkins T, Jaffe N, Colodny A, et al. The management of testicular tumors in children. J Uro11978;120:96-102. 2. Bhargava M, Reddy D. Tumors of the testis. Cancer1966;19:1655-1665. 3, Exelby P. Testis cancer in children. Semin Onco11979;6:116-120. 4, Tapper D, Lack E. Teratomas in infancy and childhood. Ann Surg 1983; 198(3):398-410. 5. Hudson M, Konvolinka C, Deshmukh N. High-grade immature teratoma of the testis in infancy. Mil Med 1992;157(9):501-4. 6. Carney J, Thompson D, Johnson C, et al. Teratomas in children: clinical and pathological aspects. J Pediatr Surg 1972;7:271-282. 7, Mahour G, Woolley M, Trivedi $, et al. Teratomas in infancy and childhood. Surgery 1974;76:309-318. 8, Billmire D, Grosfeld J. Teratomas in childhood: analysis of 142 cases. J Pediatr Surg 1988;21:548-551. 9. Liu P, Phillips M, Edwards V, et al. Sonographic findings of testicular teratoma with pathologic correlation. Pediatr Radio11992;22:99-101. 10. Barth R, Teele R, Colodny A, et al. Asymptomatic sorotal masses in child ren. Radiology 1984; 152:65-68. 11. Mostofi F, Price E. Tumors of the male genital system: atlas of tumor pathology. Washington, DC: Armed Forces Institute of Pathology, 1973:59. 12, Green D. The diagnosis and treatment of yolk sac tumors in infants and children. Cancer Treat Rev 1983; 10:265-288.