Testicular Pathology

Radiology - Pathology

Before You Begin

This module is intended primarily for pre-clinical studentslearning or reviewing pathophysiology.

Please note that this series will focus on how pathology presents in imaging studies. It assumes familiarity with fundamental anatomy. If you need to learn or review this core concept, please visit the “Anatomy” section of our website.

If material is repeated from another module, it will be outlined as this text is so that you are aware

Based on Publication from Radiographics

Radiographic appearance of the normal testicle

Testes initially form in the lumbar region of the abdomen and successfully migrate to the scrotum 97% of the time for full-term male infants. Most testis that are undescended at birth (cryptorchidism) move to the scrotum at 3 months

The testicles are superficial organs and are best initially imaged with high frequency ultrasound (no radiation)

Testicular echotexture should be homogeneous

Doppler flow can be assessed/confirmed within the testicular parenchyma

Normal Testicle

Homogeneous testicular echotexture with normal Doppler flow

Testicular Pathology

A. Non neoplastic (palpable lump that is not malignant)

B. Neoplastic (i.e. palpable lump that is malignant)

C. Ischemia/torsion

D. Infectious/inflammatory

D. Post traumatic

Ultrasound work up for a scrotal lump

1. Intratesticular or extra testicular?

Extratesticular lesions are more commonly

benign

Intratesticular lesions are more commonly

malignant

2. Solid or cystic (see “intro to rad path” module for review)

Solid intratesticular lesions are worrisome

3. Single or multiple?

If multiple, think mets/lymphoma (intro to rad path)

Scrotal Lump

US image shows an anechoic extratesticular cyst (calipers) which is

separate from the testicle (*). This was an epididymal cyst/spermatocele

*

Testicular Pathology Benign

Color Doppler US image shows an anechoic intratesticular cyst (arrow) with

no internal vascularity. This is a testicular cyst (benign).

Testicular Pathology Malignant

Seminoma in a 33-year-old man. (a) Gray-scale

US image shows a homogeneous lobular

intratesticular mass (arrow). (b) Color Doppler

US image shows internal blood flow in the mass

(arrow). (c) Photograph of the gross specimen

shows a lobular homogeneous mass

(arrow). (d) Photomicrograph (original

magnification, ×400; hematoxylin-eosin [H-E]

stain) of the specimen shows fried egg–like

neoplastic cells (arrows)

*ba c

d

Testicular Tumors

Solid intratesticular mass with internal vascularity represents a testicular tumor until proven otherwise

Can be divided into seminomatous and nonseminomatous tumors

Remember that the testes originated in the perilumbar region. Lymphatic drainage follows venous drainage such that testicular malignancies will drain into the para-aortic nodes

Testicular Metastases—Path of Spread

Axial contrast-enhanced computed tomographic (CT) image shows a large (>5-cm)

retroperitoneal mass (arrow) surrounding the aorta (*) at the level of the kidneys

*

Testicular Tumors

Germ Cell Tumors

1. Seminoma

2. Embryonal carcinoma

3. Yolk sac tumor

4. Teratoma

5. Mixed germ cell tumor

Sex cord-stromal tumors

1. Leydig cell tumor

2. Sertoli cell tumor

3. Granulosa cell tumor

4. Thecoma-fibroma

Miscellaneous tumors:

1. Lymphoma (especially if multiple)

2. Leukemia (especially if multiple)

3. Sarcoma

Mixed NSGCT in a 57-year-old

man. (a) Gray-scale US image shows

a partially cystic and partially solid

intratesticular mass (arrow).

(b) Photograph of the gross

pathologic specimen shows cystic

spaces within the mass (arrow).

(c)Photomicrograph (original

magnification, ×200; H-E stain) of the

specimen shows yolk sac and

embryonal cell carcinoma elements

(arrow).

a

b

c

Testicular Cancer Fake Outs:Blood and Pus

Intratesticular abscess mimicking a tumor. Color Doppler US image shows a 2-cm intratesticular mass

with internal echoes, no definite internal blood flow, and perilesional hyperemia (solid arrow). A

complex hydrocele is also visible (dashed arrow). The intratesticular lesion did not resolve after

intravenous antibiotic therapy, and the patient underwent orchiectomy. Photomicrograph (original

magnification, ×100; H-E stain) of the specimen shows purulent debris.

Acute pain: Think torsion or infection

Which testicle is abnormal?

18-year-old male, who was awoken from

sleep with severe left testicular pain. US

demonstrates no flow in the left testicle.

Notice the normal flow in the right testicle.

The urologist was able to detorse the

testicle and restore flow to the testicle

which “pinked up” in the operating room.

Which side is abnormal?

40 year old with right sided pain and epididymitis. Note the enlarged and hypervascular epididymal head (*) and testicle (arrow)

*

Epididymo-orchitis

• Epididymitis is inflammation of the epididymis and may extend into the testis like this case

• Infectious process that usually originates in the bladder or prostate gland, extends through the lymphatics of the spermatic cord to the epididymis and may reach the testis

• Presents as mild tenderness to a severe febrile process with unilateral pain

• The involved epididymis is usually enlarged and hypervascular

Scrotal Trauma—Which side is abnormal?

Testicular Rupture

45 year old third base coach (not wearing his cup) hit by a foul ball

There is no Doppler flow to the shattered left testicle (compare this with the normal

flow to the right testicle). Also the testicular parenchyma is amorphous (i.e. it is

difficult to draw a line around the border of the testicle).

Testicular Pathology Summary

Remember the ultrasound work up:

1. Intra or extra testicular?

2. Solid or cystic?

3. Single or multiple?

4. Is there flow?

Solid intratesticular mass represents tumor until proven otherwise

END