Bilateral testicular adrenal rest tissue in congenital adrenal hyperplasia: US and MR features

Imaging of Scrotal Tumors

음낭 종양은 고환, 부고환, 정삭, 고환막 등에서 발생하며 악성 가능성을 평가하는데 가장 중요한 요소는 병변의 위치이다. 추가적인 영상 소견과 임상 정보를 종합하여 효과적으로 진단 할 수 있다. 초음파검사는 표재성 기관인 음낭을 관찰하기 용이하며, 우수한 영상 품질을 바탕으로 병변의 유무뿐만 아니라 위치와 성상까지 확인 가능하다. 초음파검사로 감별이 어려울 경우에는 자기공명영상을 이용하여 지방, 출혈, 섬유화, 조영증강 등 추가적인 종양의 특징을 확인하는 것이 진단에 도움이 된다. 전산화단층촬영은 고환암의 병기결정이나 복강 내 미하강고환의 위치를 탐색하는데 유용하다. 본 종설에서는 고환 내외에서 발생하는 음낭 종양의 영상 소견을 살펴보고자 한다.

Sonographic features of the testicular adrenal rests tumors in patients with congenital adrenal hyperplasia: a single-center experience and literature review

PURPOSE

Testicular adrenal rests tumor (TART) is a rare kind of benign tumor in the testis. It usually occurred secondary to congenital adrenal hyperplasia (CAH), a hormonal disorder caused by hydroxylase deficiency. As the first-line examination method, ultrasound provides crucial diagnostic information for TART, although misdiagnosis to malignancy is quite common because of its rare prevalence. We aimed to summarize the sonographic manifestations of TART to improve the diagnostic accuracy and specificity.

METHODS

Eight CAH patients with TART identified by ultrasound in our medical center were retrospectively reviewed. Clinical and hormonal profile, semen analysis and treatment choices were collected. Sonographic examinations were performed at the first evaluation and interpreted by experienced radiologists individually. All patients received regular follow-up, and 5 patients undertook repeated scrotal ultrasound. A literature review of TART in CAH patients was conducted, with 123 patients from 23 articles since 1990 included.

RESULTS

A total of 8 patients aged between 4 to 27 years old were enrolled. 7 of 8 (87.5%) patients exhibited bilateral testicular lesions. The sizes of the testicular lesions were between 0.18 ml to 5.68 ml, and all showed a clear boundary. 10/15 (66.7%) lesions were homogenously hypoechoic, 4/15 (26.7%) were heterogeneously iso-hypoechoic, and 1/15 (6.7%) were homogenously isoechoic. 10/15 (66.7%) lesions were hyper-vascular. The longitudinal follow-up of 5 patients showed testicular lesions changed in terms of size, echogenicity, and vascularity after steroid treatment. A potential correlation may exist between ACTH levels and tumor size (p = 0.066). From the literature review, 100/123 (81%) patients got bilateral lesions, and 95% of them were located near the mediastinum. 80/103 (78%) lesions exhibited a clear boundary, and predominant lesions (74%) were hypoechogenic. Vascularity was with great diversity. Seventy-nine lesions of 44 patients were followed-up by scrotal ultrasound, among which 29 (37%) remained unchanged, 29(37%) shrank, and 21(27%) disappeared.

CONCLUSIONS

Key sonographic characteristics of TART are: resembled lesions on both testes, located near the mediastinum, clear boundary, and changed in size or echogenicity after steroid treatment. These features can help radiologists to make an accurate diagnosis of TART.

Para-ovarian adrenal rest tumors: gynecologic manifestations of untreated congenital adrenal hyperplasia

Congenital adrenal hyperplasia (CAH) is an inherited disorder of adrenal steroidogenesis often diagnosed in infancy. Gynecologists may encounter adult patients with CAH due to the clinical effects of increased androgens, e.g. hirsutism, clitoromegaly, oligomenorrhea, or, rarely, pelvic masses. This case report reviews the association of para-ovarian adrenal rest tumors with CAH, and the role of gynecologists in their evaluation and treatment. A 23-year-old woman with CAH (21-hydroxyase deficiency) untreated for the past 5 years presented with a pelvic mass and elevated serum testosterone (1433 ng/dL) and plasma ACTH (1117 pg/mL). Intraoperative findings revealed multiple retroperitoneal masses. Final pathology demonstrated adrenal rest tissue. Para-ovarian and ovarian adrenal rest tumors may present as a rare gynecologic manifestation in patients with untreated CAH.

Two cases of reversible male infertility due to congenital adrenal hyperplasia combined with testicular adrenal rest tumor

Cases

Testicular adrenal rest tumor (TART) is one of the possible causes of male infertility, accompanied by congenital adrenal hyperplasia (CAH). Here are reported two cases of TARTs that were referred to Kobe City Medical Center West Hospital for the treatment of infertility and testicular tumors.

Outcome

In one case, the semen analysis was improved from oligoasthenozoospermia to normozoospermia after taking oral glucocorticoid supplementation. The other case of original azoospermia showed that sperm had ejaculated into the semen after taking oral glucocorticoid supplementation.

Conclusion

Although the prevalence of TARTs in male infertility is very rare, it is important to know how to approach this disease, considering the curable pathology of spermatogenesis and tumors resembling an appearance to germ cell tumors.

Sonography and Magnetic Resonance Imaging Characteristics of Testicular Adrenal Rest Tumors

BACKGROUND

The aim of this study was to describe the gray-scale and color Doppler ultrasonography (US) and magnetic resonance (MR) imaging features of testicular adrenal rest tumors (TART) in patients with congenital adrenal hyperplasia.

MATERIAL/METHODS

Forty-one patients with congenital adrenal hyperplasia were evaluated by gray-scale and color Doppler ultrasonography. Totally eighteen adrenal rest tumors in 9 patients were diagnosed TART on US and MR imaging. Gray-scale and color Doppler US and MR findings of the patients were documented.

RESULTS

A total of eighteen masses were evaluated in nine patients. The mean age of these patients was 14.3±4.5 (range 10.1-23.3) years. US revealed hypoechoic lesions around the mediastinum testis with hypervascularity dispersing in ten patients and hypovascularity in two patients. In six patients, the lesions were hyperechoic with poor vascularity. Lesions exhibited homogeneous (n=8) and heterogeneous (n=10). Testicular microlithiasis was present in 4 of 9 patients with TART. Doppler ultrasound showed normal testicular vessels passing through the mass which were undisturbed, not displaced and not change in caliber. MRI features were the following: all lesions were hypointense on T2- and hyperintense (n=12) and isointense (n=6) on T1-weighted images. All masses revealed homogeneous contrast enhancement on postcontrast T1-weighted images.

CONCLUSIONS

Ultrasonography and MRI are good methods for detecting and monitoring TART. US is the first preferable modality because it is quick and cheap than MRI. Bilateral mostly hypoechoic lesions depicted around the mediastinum testis with no mass effect is highly suggestive for the diagnosis of testicular adrenal rest tissues on ultrasonography. Normal testicular vessels coursing through the lesions undisturbed and not change in caliber is described specific for this kind of tumors.

Sonographic Appearance of Testicular Adrenal Rest Tumour in a Patient with Congenital Adrenal Hyperplasia

Background

Testicular adrenal rest tumours (TARTs) are benign testicular masses that are found in inadequately treated patients with congenital adrenal hyperplasia (CAH). Recognizing this association and identifying characteristic ultrasound features of TARTs is important so as to avoid misdiagnosing them as malignancies, which can lead to unnecessary interventions.

Case Report

We describe a case of a 9-year-old boy, with a diagnosis of CAH and precocious puberty, who was referred to our department for an ultrasound evaluation of the abdomen and scrotum. On ultrasound, there were well-defined, heterogeneous, predominantly hypoechoic, round-to-oval masses in both testes. Taking into account the presence of CAH and a typical sonographic appearance of bilateral testicular masses, a diagnosis of testicular adrenal rest tumour was made; biopsy was deferred and hormonal treatment was modified.

Conclusions

Prompt diagnosis of testicular adrenal rest tumours is essential, as it only indicates inadequate hormonal control. Moreover, it can prevent unnecessary biopsies and orchidectomies, and can maintain fertility. TARTs have a typical imaging appearance that every radiologist must be aware of.

Magnetic resonance imaging of the scrotum: pictorial review with ultrasound correlation

The purpose of this review is to showcase the added value of scrotal magnetic resonance imaging (MRI) in the workup of neoplastic and non-neoplastic entities. While ultrasound (US) remains the first-line imaging modality for evaluating scrotal pathology, MRI may add valuable information, particularly when US findings are equivocal. The inherent soft tissue resolution characteristics of MRI, as well as the ability to detect subtle enhancement and provide wider field-of-view imaging, can prove useful in evaluating inconclusive US findings. The added value of MR in these instances is critical as it may have a significant impact on patient management.

Sonographic Detection of Accessory Adrenal Tissue in Neonates

OBJECTIVES

The purpose of this study was to describe the incidence and appearance of accessory adrenal tissue in neonates, as diagnosed by high-resolution sonography, and increase the awareness of this entity.

METHODS

We examined the adrenal glands in 153 neonates referred for renal and urinary tract sonography at our institution between January 2014 and January 2015. All kidneys and adrenal glands, except for ectopic kidneys, were scanned with the neonate prone and a linear array transducer with frequency of 11 or 14 MHz.

RESULTS

In 9 neonates (5.9%), sonography showed a round, well-defined structure adjacent to the adrenal gland with a hyperechoic center and hypoechoic periphery, similar to the echogenicity of the normal adrenal medulla and cortex, respectively. The largest diameter of the structure measured 2.9 to 4.5 mm. On follow-up studies, which were available for 7 neonates, the structure was not evident, and the suprarenal area was normal.

CONCLUSIONS

Accessory adrenal tissue can be identified in the suprarenal area in neonates with high-resolution sonography. Radiologists and sonographers caring for neonates should be aware of this finding and not confuse it with disease.

Ovary and testicle and everything in between: lesions and imaging in the newborn

Assessment of the neonatal reproductive tract requires an understanding of embryology, awareness of common clinical presentations, and familiarity with normal newborn variation. This review of the neonatal reproductive tract emphasizes the use of sonography in the evaluation of developmental, acquired, and neoplastic conditions in male and female newborns. Anchored in embryologic origins, the discussion also includes descriptions of findings that may be encountered in prenatal imaging. Comments on clinical correlation are included to guide appropriate triaging of these complex cases. Imaging pearls and pitfalls are incorporated into this review, including the recognized effects of maternal hormones in female infants.

Adrenal rest tissue in gonads of patients with classical congenital adrenal hyperplasia: multicenter study of 45 French male patients

OBJECTIVES

Several cases of testicular adrenal rest tumours have been reported in men with congenital adrenal hyperplasia (CAH) due to the classical form of 21-hydroxylase deficiency but the prevalence has not been established. The aims of this report were to evaluate the frequency of testicular adrenal rest tissue in this population in a retrospective multicentre study involving eight endocrinology centres, and to determine whether treatment or genetic background had an impact on the occurrence of adrenal rest tissue.

MATERIAL AND METHODS

Testicular adrenal rest tissue (TART) was sought clinically and with ultrasound examination in forty-five males with CAH due to the classical form of 21-hydroxylase deficiency. When the diagnosis of testicular adrenal rest tumours was sought, good observance of treatment was judged on biological concentrations of 17-hydroxyprogesterone (17OHP), delta4-androstenedione, active renin and testosterone. The results of affected and non-affected subjects were compared.

RESULTS

TART was detected in none of the 18 subjects aged 1 to 15years but was detected in 14 of the 27 subjects aged more than 15years. Five patients with an abnormal echography result had no clinical signs. Therapeutic control evaluated at diagnosis of TART seemed less effective when diagnosis was made in patients with adrenal rest tissue compared to TART-free subjects. Various genotypes were observed in patients with or without TART.

CONCLUSION

Due to the high prevalence of TART in classical CAH and the delayed clinical diagnosis, testicular ultrasonography must be performed before puberty and thereafter regularly during adulthood even if the clinical examination is normal.

Testicular adrenal rest tumors in patients with congenital adrenal hyperplasia: prevalence and sonographic, hormonal, and seminal characteristics

OBJECTIVE

Testicular adrenal rest tumors have been described in patients with congenital adrenal hyperplasia (CAH). The aim of this work was to (1) evaluate the prevalence of testicular adrenal rest tumors in patients with CAH; (2) study the hormonal profile; (3) define the sonographic features; (4) assess the seminal profile; and (5) initiate a longitudinal study on the possible role of corticotropin (ACTH) plasma levels in the induction and persistence of testicular adrenal rest tumors.

METHODS

Eighteen patients affected by CAH, aged 21 to 41 years, were studied. These were all patients referred to our endocrinology unit for the first time to undergo a clinical evaluation. All of the patients were taking long-term cortisone acetate and fludrocortisone replacement therapy. The study included (1) a physical examination, (2) testis sonography, (3) a hormonal profile, (4) semen analysis.

RESULTS

Sonography showed testicular adrenal rest tumors in 11 patients (61.1%); of these, 9 cases (50.0%) were bilateral, and 2 (11.1%) were unilateral. The diameter ranged from 4 to 38 mm. In 9 patients, the lesions were hypoechoic, whereas in 2, they were hyperechoic. High plasma ACTH levels were detected in all of the patients with tumors despite long-term therapy. Semen analysis found 2 cases of azoospermia and 6 cases of oligoasthenoteratozoospermia; the 3 remaining patients were normospermic. The preliminary longitudinal study has shown 3 patients with a disappearance or reduction of the tumors after 6 months of modified treatment.

CONCLUSIONS

This study confirms the high prevalence of testicular adrenal rest tumors in patients with CAH and the major role played in its pathogenesis by high plasma ACTH levels.

[Testicular adrenal rests: the role of imaging]

Testicular adrenal rests are encountered in ACTH hypersecretion syndromes, most often in congenital adrenal hyperplasia attributable to a deficit in 21-hydroxylase. They are discovered clinically or on systematic sonography, generally in the young adult. On sonography, they appear as confluent hypoechogenic masses, often bilateral, that have developed in the region of the testicular hilum. At a late stage, they take on a highly suggestive attenuating aspect. In color Doppler, they have a regular vascular architecture. They generally regress or stabilize with replacement glucocorticosteroid treatment. They can sometimes progress, which then poses the problem of the type of lesion. Biopsy or spermatic vein samples are not reliable. MRI contributes very little more than sonography. Diagnosis comes with follow-up or, as a last resort, orchidectomy.

Testicular adrenal rests in a patient with congenital adrenal hyperplasia: US and MRI features

We present ultrasonographic and magnetic resonance imaging findings of intratesticular adrenal rests in a 16-year-old patient with congenital adrenal hyperplasia. Scrotal ultrasonography showed bilateral well-delineated homogenous hypoechoic lesions located around the mediastinum testis, which were highly vascularized on power Doppler ultrasonography. Relative to normal testicular parenchyma the lesions were iso- or hyperintense on T1-weighted and hypointense on T2-weighted images. T2-weighted images also showed a target-like appearance caused by a more hypointense peripheral halo around the lesions. The lesions enhanced remarkably on post-contrast images. This case suggests that radiological evaluation of testes, even in the presence of normal physical examination findings, should be included in periodical follow-up of patients with congenital adrenal hyperplasia. Magnetic resonance (MR) imaging is useful in demonstrating the lesions, because the contrast resolution better than with ultrasonography.

Sonography of Benign Intrascrotal Lesions

Ultrasound plays an important role and adds essential information in diagnosing benign intrascrotal lesions. Characterization of benign intrascrotal lesions with sonography, in combination with clinical assessment, can lead to nonsurgical management or testicular sparing surgery. We present important sonographic features of benign intrascrotal lesions, including extratesticular lesions: adenomatoid tumors, papillary cystadenomas, spermatoceles, hydroceles, varicoceles, hernias; and intratesticular lesions: tunica albuginea cysts, testicular simple cysts, epidermoid cysts, tubular ectasia of the rete testis, intratesticular varicoceles, adrenal rest tumors, and splenogonadal fusion. The goal of this review is to provide the radiologist with a better understanding of benign lesions that occur in the scrotum.

Testicular adrenal rest tumours in postpubertal males with congenital adrenal hyperplasia: sonographic and MR features

The purpose of this study was to investigate the prevalence of testicular adrenal rest tumours in patients with congenital adrenal hyperplasia (CAH), and to describe sonographic and MR features of these lesions. Seventeen postpubertal male CAH patients underwent scrotal sonography, with colour Doppler, and in 16 of them pre- and postcontrast enhanced T1- and T2-weighted MR images of the testes were obtained. Ultrasound revealed lesions in 16 of 17 patients (94%), bilateral in 10 patients and unilateral in 6 patients. The lesions were typically located adjacent to the mediastinum testis. The maximal diameter of the lesions varied from 2 to 40 mm. Margins were blurred in 11 of 31 lesions. Seventeen of the 20 lesions smaller than 2 cm in diameter were hypoechoic, whereas all 11 lesions larger than 2 cm showed hyperechoic reflections. On MR all lesions were isointense on T1- and hypointense on T2-weighted images and lesion margins were clearly defined. Enhancement of the lesions after intravenous contrast was seen in 13 of 15 patients. In our series the prevalence of testicular adrenal rest tumours in postpubertal CAH patients is much higher than in other reported studies. The lesions may develop from some small, hypoechoic, and multifocal nodules and coalesce to large hypoechoic lesions with hyperechoic reflections on ultrasound. As our results suggest that ultrasonography and MR show the lesions equally well, ultrasonography should be the method of first choice for detection and follow-up of these lesions, because it is the cheapest and quickest imaging technique. In case of a partial orchiectomy, MR is recommended because it shows lesion margins optimally.