Benign and malignant scrotal neoplasms

Most common malignancy in men 15-35 yrs of age

Scrotal neoplasms

Most extratesticular masses are ___________

Malignant

Most intratesticular masses are ____________

Benign

Most common “pure” germ cell tumor of testes

Seminoma

Seminoma is most common in ______________

While males

Seminoma

Normal AFP but INCREASED hCG

Increased risk of seminoma formation in pts with cryptorchidism

Spreads to retroperitoneal lymph nodes first

Pure seminomas have best prognosis of all germ cell tumors, very responsive to treatment

Can be cured when unilateral orchiectomy is performed

Seminoma is associated with

Trisomy 21, Klinefelter syndrome, smoking

USA Seminoma

Solid round or oval tumor

Uniform low level echoes, WITHOUT calcification

Hypoechoic to surrounding tissues

Tumors >1.6cm have hypervascularity

Rarely become necrotic or cystic

Seminoma

Non-seminomatous germ cell tumors

Germ cell tumors are divided into seminomatous (pure seminoma) and non-seminomatous (seminoma and non-seminoma portions) groups

More aggressive than seminoma

Cause visceral mets

Requires orchiectomy

Generally unresponsive to radiation or chemotherapy

• Mixed malignant germ cell

• Embryonal cell carcinoma

• Yolk sac tumor

• Teratoma

• Choriocarcinoma

Embryonal cell carcinoma

Men age 25-35yrs

Labs: AFP and beta hCG elevated in most cases

Any tumor that secretes high levels of bhCG can lead to gynecomastia

Most aggressive testicular malignancy

Embryonal cell carcinoma

Most aggressive cancer with invasion of tunica albuginea

Embryonal cell carcinoma

Embryonal cell carcinoma USA

More heterogeneous than seminoma

Can have solid and cystic portions along with coarse calcifications

Distortion of the organ contour with tumor invasion

Embryonal cell carcinoma

Most common non-seminomatous germ cell tumor

Mixed germ cell tumors

Mixed germ cell tumors

Contains two or more types of germ cell tumor tissue

Lab testing on the tumor types that make up the mass

Usually occur age 20-30

Rarely occur before puberty or after 50

Most common combination is teratoma and embryonal cell carcinoma

USA varies with components

Not possible to distinguish sub-types by sonography

Second most common primary malignancy of the testicles

Mixed germ cell tumors

Mixed germ cell tumor

Most common testicular tumor in pts <2 yrs of age

Yolk sac tumor

Yolk sac tumor

5 year survival rate 25-35%

Lab testing: elevated AFP, normal bhCG

May see cystic areas and echogenic foci due to hemorrhage and necrosis

2nd most common testicular tumor in infants and young children

Teratoma

Teratoma

Usually benign but can malignant

1/3 mets within 5 years

If found in adults → Usually malignant

Contains bone, cartilage, smooth muscle and other tissues

Labs: Elevated AFP and bhCH with malignancy

Any tumor that secretes high levels of bhCG can lead to gynecomastia

Teratoma USA

Large heterogeneous, complex mass

Calcs and cystic components

Teratoma

Choriocarcinoma

Rarest type of germ cell tumor

Most common in ages 20-30yrs

Lab testing: causes increased levels of beta hCG, AFP levels usually normal

Mets early, worst prognosis of all germ cell tumors

Any tumor that secretes high levels of bhCG can lead to gynecomastia

Stromal cell tumors

Leydig cell

Sertoli cell

Granulosa cell

Mixed

Leydig cell tumors

>85% benign

Occurs in pts age 5-10years or 30-60 years

Painless, palpable mass

Normal AFP, beta hCG levels

Produce testosterone and sometimes estrogen

Can cause endocrine imbalance with estrogen and testosterone (endocrinopathy) leading to precocious puberty, impotence, gynecomastia

Leydig cell tumors USA

Small (<1cm), solid homogeneous

Large, mildly irregular borders

Hypoechoic

Increased peripheral vascularity is usually benign

Areas of hemorrhage seen

Leydig cell tumor

Sertoli cells tumors

Rare; malignant or benign

Painless mass

Similar to Leydig cell tumor in symptoms and appearance

Tumor may calcify

Can cause endocrine imbalance with estrogen and testosterone (endocrinopathy) leading to precocious puberty and gynecomastia

Bilateral and multifocal

Sertoli cell tumor

Mixed germ and stromal cell tumor

Gonadoblastoma - gonadal stromal tumor cells combined with germ cell tumor cells; majority occurs with cryptorchidism and hypospadias

Germ cell stromal - seX cord cells

Testicular mets

Most commonly comes from prostate or lung primary

Usually multiple tumors identified

More common than germ cell tumors in pts >50yrs old

Primary carcinoma is typically unilateral, while secondary carcinoma is typically bilateral

Most common bilateral testicular tumor

Lymphoma

Most common secondary malignancy of the testes

Lymphoma

Lymphoma

Majority of pts diagnosed at age 60-70 years

Extension into the epi and cord is common

Can be focal or diffuse

Lymphoma USA

Homogeneous and hypoechoic tissue replaces the testes tissue

Hemorrhage and necrosis is rare

Increased vascularity

Lymphoma

Leukemia

2nd most common mets neoplasm

Can be focal or diffuse

An be unilateral or bilateral

Leukemia USA

Nonspecific, similar to lymphoma

Hypoechoic enlargement of the teste

Hypervascularity

Leukemia

Rare tumors

Adrenal rests

Epidermoid cyst

Malakoplakia

Carcinoid

Mesenchymal

Arenal rests

Associated wish Cushing syndrome and adrenal hyperplasia

Hypoechoic, multifocal masses

Wheel spoke vascularity

Adrenal rest tumor

Sarcoidosis

Presents as recurrent epididymis

USA Sarcoidosis

Inflammatory disease that can affect multiple organs

Can be found in testicles and/or epi

Irregular, hypoechoic solid mass in testicle

Can also be diffuse with multiple hypoechoic nodules

Enlarged epididymis with hypoechoic nodule formation

Sarcoidosis

Benign extratesticular tumors

While most intratesticular tumors are malignant, most extratesticular tumors are benign

Most involve the epididymis

Gentle transducer can be used to demonstrate the mass can move independently of testis

Sarcoidosis can form nodules in the epididymis

Spermatic granulomas are a common residual effect of a vasectomy

Adenomatoid tumor

Most common Benign extratesticular tumors

Adenomatoid

Adenomatoid USA

• Rounded or ovoid with varying echogenicity

• Well circumscribed

• Hypovascular/avascular on color Doppler eval

Adenomatoid USA

Adenomatoid tumor

Extratesicular malignant neoplasms

Fibrosarcoma

Lipsarcoma

Lymphoma

Rhabdomyosarcoma

Mets

Which of the following is normal with seminomatous tumors but abnormal with non-seminomatous tumors:

AFP levels

bhCG

Testosterone

WBC

AFP levels

When a solid tumor is identified in the testicle, what should be done to further evaluate this pt

Aortic evaluation

What can be used to described the expected ultrasound appearance of a testicular seminoma tumor?

Hypoechoic with low-level internal echoes

Non-seminomatous tumors are:

More aggressive than seminomatous tumors

Unresponsive to treatment

Cause visceral mets

All of the above

All of the above

Which of the following tumors would present with elevated AFP and bhCG levels?

Mixed germ cell

Embryonal cell carcinoma

Testicular teratoma

All of the above

All of the above

Any germ cell tumor that secretes high levels of bhCG can lead to the formation of:

Gynecomastia

What benign tumor is associated with estrogen

Leydig cell

Primary testicular cancer is typically _________, while secondary testicular cancer is typically _______

Unilateral, bilateral

What are the two most common secondary testicular cancers?

Lymphoma and leukemia

What scrotal mass is associated with Cushing syndrome

Adrenal rest