The diagnosis and management of scrotal masses

ACR Appropriateness Criteria® Newly Diagnosed Palpable Scrotal Abnormality

Palpable scrotal abnormalities are caused by a variety of disorders, ranging from indolent benign conditions to aggressive tumors, and infectious and vascular processes. In these patients the diagnostic workup typically begins with a complete clinical, history, and physical examinations, including analysis of risk factors. If imaging is required, ultrasound examination is the diagnostic modality of choice. In few select patients with very large scrotal masses, MRI may be appropriate. However, the use of gadolinium-based contrast should be evaluated critically depending on specific patient factors. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Giant Primary Scrotal Lipoma: A Rare Entity with Diagnostic Pitfalls

Primary scrotal lipomas are rare. We describe the case of a 47-year-old male with a giant scrotal lipoma who underwent a surgical excision. We report the clinical and radiological approach as well as the treatment of this atypical benign tumor.

Imaging of scrotal masses

Testicular cancer is responsible for approximately 0.1% of all cancer deaths in the USA, and seminoma is the most common type of testicular tumor. Ultrasonography is the primary imaging modality for accessing testicular and extratesticular lesions, while magnetic resonance imaging can be used for problem solving in lesion characterization in certain cases. CT imaging is usually performed for retroperitoneal staging of testicular cancer metastasis and follow-up after treatment. Extratesticular masses are common, yet rarely malignant. Imaging plays an important role in primary diagnosis of testicular cancer and differentiating it from common non-neoplastic findings. The purpose of this article is to review various imaging findings in testicular and extratesticular masses.

Fibrous Hamartoma of Infancy in the Scrotum

Fibrous hamartoma of infancy is a solid benign tumor of the subcutis, which usually occurs within the first 2 years of life. It predominantly occurs in males, and is clinically presented as a solid, painless, well-limited subcutaneous formation, tending to grow, and in most cases without any symptoms. It occurs in various locations. The aim of this case report was to present a case of a rare tumor of infancy in the scrotal region, in an 8-month-old male infant, with a nonspecific clinical picture, suggestive of a malignant formation, thus presenting a diagnostic challenge for a doctor. The tumor was completely removed. The diagnosis was confirmed by histopathological analysis. One year after the surgical procedure, a follow-up ultrasonography examination showed no relapse.

Sarcoidosis is a rare cause of infertility: A case report

In this paper, we presented a patient, who applied to our clinic because of infertility. After an intensive investigation, we diagnosed systemic sarcoidosis with testicular involvement. Urogenital sarcoidosis is a rare and insidious condition, however, it can lead to infertility. Therefore, following the diagnosis, we applied systemic steroid therapy to the patient. Within one year, the patient had a child without assisted reproductive techniques. According to our experience, in this case, we concluded that infertility without an etiology should be investigated elaborately. Furthermore, urogenital sarcoidosis should keep in mind as a rare etiology.

Sonographic findings of mass-forming extramammary Paget's disease in the scrotum

Extramammary Paget's disease (EMPD) is a rare cutaneous malignancy involving the scrotum and may be confused with other scrotal malignancy. We describe the sonographic findings of an extremely rare case of mass-forming EMPD of the scrotal wall. Ultrasonography, which shows mild heterogeneous hyperechoic masses with a stalk connected to the dermis, can help predict the depth of vertical invasion of the lesion. The lesion extent should be precisely evaluated because the presence of dermal invasion of EMPD is the risk factor in distant metastasis and is known to result in a worse prognosis. Ultrasonography is a primary imaging modality to evaluate the extent and vertical invasion of EMPD. Surgical local wide excision is the treatment of choice for EMPD and histopathology confirmed the diagnosis.

Testicular microlithiasis: what urologists should know. A review of the current literature

Introduction

Testicular microlithiasis is a finding incidental to the ultrasound examination of the scrotum. This article presents some new data regarding the etiopathology of testicular microliths. As there is a growing body of literature available, which associates testicular microlithiasis with a testicular germ cell tumor or male infertility, our review focuses on these relations (based on a new meta-analysis and retrospective follow-up programs). The purpose of this review is to summarize the knowledge about testicular microlithiasis and discuss the latest recommendations.

Material and methods

A comprehensive literature review was performed using Science Direct and Scopus with MeSH terms and keywords 'testicular microlithiasis', testicular tumor', male infertility'.

Results

The clinical consequences of testicular microlithiasis depend on the co-occurrence of specific risk factors. The presence of testicular microlithiasis alone in the absence of risk factors is not an indication for further investigation.

Conclusions

A link between testicular microlithiasis and testicular cancer as well as male infertility has been analyzed. Follow-up is only recommended where risk factors of testicular cancer other than testicular microlithiasis are present.

Sonographic imaging of extra-testicular focal lesions: comparison of grey-scale, colour Doppler and contrast-enhanced ultrasound

Extra-testicular lesions are usually benign but present with nonspecific grey-scale sonography findings. This study assesses conventional sonographic characteristics in the differentiation of extra-testicular tumoural from inflammatory lesions and whether contrast-enhanced ultrasound has a role. A retrospective database analysis was performed. All patients were examined by experienced sonographers employing standard techniques combining grey-scale, colour Doppler sonography and contrast-enhanced ultrasound. Features recorded were: clinical symptoms, size, location, echogenicity, colour Doppler sonography and contrast-enhanced ultrasound enhancement. Vascularity on colour Doppler sonography and contrast-enhanced ultrasound was graded and compared. The lesions were classified as tumoural or inflammatory. The Chi-square test was used to analyse the sonographic patterns and kappa coefficient to measure the agreement between colour Doppler sonography and contrast-enhanced ultrasound. A total of 30 lesions were reviewed (median diameter 12 mm, range 5-80 mm, median age 52 years, range 18-86 years), including 13/30 tumoural and 17/30 inflammatory lesions. Lesions were hypoechoic (n = 12), isoechoic (n = 6), hyperechoic (n = 2) or mixed (n = 10). Grey-scale characteristics of tumoural vs. inflammatory lesions differed significantly (P = 0.026). On colour Doppler sonography, lesions had no vessels (n = 16), 2-3 vessels (n = 10) and ≥4 vessels (n = 4). On contrast-enhanced ultrasound, lesions showed no vascularity (n = 17), perfusion similar to testis (n = 7) and higher (n = 6). All abscesses identified (n = 9) showed no vascularity on both colour Doppler sonography and contrast-enhanced ultrasound. There was good agreement between these techniques in evaluating vascularity (κ = 0.719) and no significant difference between colour Doppler sonography and contrast-enhanced ultrasound of tumoural vs. inflammatory lesions (P > 0.05). The grey-scale appearances of extra-testicular lesions are essential for characterisation. Colour Doppler sonography and contrast-enhanced ultrasound findings are not useful in that respect. Contrast-enhanced ultrasound is excellent in establishing absence of vascularity.

MR Imaging of the Penis and Scrotum

Traditionally, due to its low cost, ready availability, and proved diagnostic accuracy, ultrasonography (US) has been the primary imaging modality for the evaluation of scrotal and, to a lesser extent, penile disease. However, US is limited by its relatively small useful field of view, operator dependence, and inability to provide much information on tissue characterization. Magnetic resonance (MR) imaging, with its excellent soft-tissue contrast and good spatial resolution, is increasingly being used as both a problem-solving tool in patients who have already undergone US and as a primary modality for the evaluation of suspected disease. Specifically, MR imaging can aid in differentiating between benign and malignant lesions seen at US, help define the extent of inflammatory processes or traumatic injuries, and play a vital role in locoregional staging of tumors. Consequently, it is becoming more important for radiologists to be familiar with the wide range of penile and scrotal disease entities and their MR imaging appearances. The authors review the basic anatomy of the penis and scrotum as seen at MR imaging and provide a basic protocol for penile and scrotal imaging, with emphasis on the advantages of MR imaging. Pathologic processes are organized into traumatic (including penile fracture and contusion), infectious or inflammatory (including Fournier gangrene and scrotal abscess), and neoplastic (including both benign and malignant scrotal and penile tumors) processes.

Comparison between Open Epididymal Cystectomy and Minimal Resection of Epididymal Cysts Using a Scrotoscope: A Clinical Trial for the Evaluation of a New Surgical Technique

OBJECTIVE

To provide a new surgical technique for epididymal cyst (EC) treatment and to assess its safety and efficiency.

METHODS

Forty-eight patients with symptomatic EC were randomized into 2 groups. One group (n = 23) received traditional open epididymal cystectomy (OEC) and the other group (n = 25) underwent minimal epididymal cystectomy with scrotoscope (MECS), which provided a clear vision of scrotal contents. Demographic information and perioperative and postoperative outcomes data were obtained and analyzed during a 2- to 6-month follow-up.

RESULTS

No significant differences between the OEC and MECS groups were found in demographic information. Compared with OEC group, the MECS group had a shorter operating time (18.6 ± 2.9 vs 54.5 ± 7.0 minutes; P <.05), shorter incision length (1.1 ± 0.2 vs 4.8 ± 0.6 cm; P <.05), and less blood loss (4.6 ± 1.6 vs 17.0 ± 3.1 g; P <.05). Except for the 8.0% rate (2 of 25) of scrotal edema after MECS and 17.4% rate (4 of 23) of scrotal hematoma after OEC, both groups resulted in 0% incidence of testis or epididymis injury, wound infection, and cyst recurrence based on postoperative outcome data. Significant differences were observed after MECS compared with those after OEC based on the rates of symptom relief (95.2% vs 61.1%; P <.05) and days of wound pain (12.1 ± 2.6 vs 17.7 ± 4.1 days; P <.05).

CONCLUSION

For the first time, our study applied scrotoscope as a new alternative technique for EC treatment. Scrotoscope provides a clear field of vision and makes tissues harvested available for pathologic examination when performing decortications of EC. The results suggest MECS may be a safe, effective, and encouraging new technique.

Changes of calcific density in pediatric patients with testicular microlithiasis

Purpose

Testicular microlithiasis (TM) is a relatively rare clinical entity of controversial significance characterized by the existence of hydroxyapatite microliths located in the seminiferous tubules. The aim of this study was to observe the natural course of changes in the calcific density of pediatric TM.

Materials and Methods

We included a total of 23 TM patients undergoing scrotal ultrasound (US) on at least two occasions from July 1997 to August 2014. We retrospectively analyzed the patient characteristics, clinical manifestations, specific pathological features, and clinical outcomes. We measured the calcified area and compared the calcific density between the initial and final USs.

Results

The mean age at diagnosis was 11.3±4.6 years, and the follow-up period was 79.1±38.8 months (range, 25.4-152.9 months). During the follow-up period, no patients developed testicular cancer. Calcific density on US was increased in the last versus the initial US, but not to a statistically significant degree (3.74%±6.0% vs. 3.06%±4.38%, respectively, p=0.147). When we defined groups with increased and decreased calcification, we found that diffuse TM was categorized into the increased group to a greater degree than focal TM (10/20 vs. 4/23, respectively, p=0.049). In addition, five of eight cases of cryptorchidism (including two cases of bilateral cryptorchidism) were categorized in the increased calcification group.

Conclusions

Diffuse TM and cryptorchidism tend to increase calcific density. Close observation is therefore recommended for cases of TM combined with cryptorchidism and cases of diffuse TM.

Ewing sarcoma of the scrotum

Nonosseous Ewing sarcoma commonly occurs in the extremities or deep soft tissues. However, cutaneous and subcutaneous locations have been reported. A 3-year-old boy presented with a 2-year history of a painless, slowly growing mid-scrotal mass. Pathology after surgical excision revealed the lesion to be Ewing sarcoma. The patient is free of metastatic disease and is currently undergoing chemotherapy. Soft-tissue malignancies must be kept in the differential diagnosis of any solid paratesticular mass in a child. Although rhabdomyosarcoma is the most common, as this case demonstrates, other rare sarcomas are also possible.