Clinical importance and prevalence of testicular microlithiasis in pediatric patients

Imaging of Pediatric Testicular and Para-Testicular Tumors: A Pictural Review

Pre- and post-pubertal testicular tumors are two distinct entities in terms of epidemiology, diagnosis and treatment. Most pre-pubertal tumors are benign; the most frequent are teratomas, and the most common malignant tumors are yolk-sac tumors. Post-pubertal tumors are similar to those found in adults and are more likely to be malignant. Imaging plays a pivotal role in the diagnosis, staging and follow-up. The appearance on ultrasonography (US) is especially helpful to differentiate benign lesions that could be candidates for testis-sparing surgery from malignant ones that require radical orchidectomy. Some specific imaging patterns are described for benign lesions: epidermoid cysts, mature cystic teratomas and Leydig-cell tumors. Benign tumors tend to be well-circumscribed, with decreased Doppler flow on US, but malignancy should be suspected when US shows an inhomogeneous, not-well-described lesion with internal blood flow. Imaging features should always be interpreted in combination with clinical and biological data including serum levels of tumor markers and even intra-operative frozen sections in case of conservative surgery to raise any concerns of malignity. This review provides an overview of imaging features of the most frequent testicular and para-testicular tumor types in children and the value of imaging in disease staging and monitoring children with testicular tumors or risk factors for testicular tumors.

The prognostic value of testicular microlithiasis as an incidental finding for the risk of testicular malignancy in children and the adult population: A systematic review. On behalf of the EAU pediatric urology guidelines panel

INTRODUCTION

The exact correlation of testicular microlithiasis (TM) with benign and malignant conditions remains unknown, especially in the paediatric population. The potential association of TM with testicular malignancy in adulthood has led to controversy regarding management and follow-up.

OBJECTIVE

To determine the prognostic importance of TM in children in correlation to the risk of testicular malignancy or infertility and compare the differences between the paediatric and adult population.

STUDY DESIGN

We performed a literature review of the Medline, Embase and Cochrane controlled trials databases until November 2020 according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) Statement. Twenty-six publications were included in the analysis.

RESULTS

During the follow-up of 595 children with TM only one patient with TM developed a testicular malignancy during puberty. In the other 594 no testicular malignancy was found, even in the presence of risk factors. In the adult population, an increased risk for testicular malignancy in the presence of TM was found in patients with history of cryptorchidism (6% vs 0%), testicular malignancy (22% vs 2%) or sub/infertility (11-23% vs 1.7%) compared to TM-free. The difference between paediatric and adult population might be explained by the short duration of follow-up, varying between six months and three years. With an average age at inclusion of 10 years and testicular malignancies are expected to develop from puberty on, testicular malignancies might not yet have developed.

CONCLUSION

TM is a common incidental finding that does not seem to be associated with testicular malignancy during childhood, but in the presence of risk factors is associated with testicular malignancy in the adult population. Routine monthly self-examination of the testes is recommended in children with contributing risk factors from puberty onwards. When TM is still present during transition to adulthood a more intensive follow-up could be considered.

A Case of Familial Male-limited Precocious Puberty with a Novel Mutation

Familial male-limited precocious puberty (FMPP), also known as testotoxicosis, is a rare cause of precocious puberty in males. It is caused by a mutation in the luteinizing hormone/chorionic gonadotropin receptor (LHCGR) gene, resulting in the receptor being constitutively activated. This causes excessive production of testosterone, leading to precocious puberty in males. Generally, boys present with signs of puberty, such as pubic hair growth, acne, and increased height velocity around the age of 2-4 years old. Like any other cause of precocious puberty, the goal of treatment is to prevent virilization and also delay closure of the epiphyseal plates to maintain adult height potential. Treatment, therefore, is aimed at decreasing the effects of testosterone, as well as stopping the conversion of testosterone to estrogen. Little is known about the long-term effects of treatment because the disorder is so rare. However, studies using bicalutamide and anastrozole have been promising. In this report, we present a boy with FMPP with a novel mutation in the LHCGR gene, who has been responding well to therapy using both drugs.

Incidence characteristics of testicular microlithiasis and its association with risk of primary testicular tumors in children: a systematic review and meta-analysis

BACKGROUND

To systematically evaluate the incidence characteristics of testicular microlithiasis (TM) in children and its association with primary testicular tumors (PTT).

METHODS

A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. A priori protocol was registered in the PROSPERO database (CRD42018111119), and a literature search of all relevant studies published until February 2019 was performed. Prospective, retrospective cohort, or cross-sectional studies containing ultrasonography (US) data on the incidence of TM or the association between TM and PTT were eligible for inclusion.

RESULTS

Of the 102 identified articles, 18 studies involving 58,195 children were included in the final analysis. The overall incidence of TM in children with additional risk factors for PTT was 2.7%. In children, the proportion of left TM in unilateral cases was 55.7%, the frequency of bilateral TM was 69.0%, and proportion of classic TM was 71.8% [95% confidence interval (CI) 62.4-81.1%, P = 0.0, I² = 0.0%]. About 93.5% of TM remained unchanged, and newly detected PTT rate was very low (4/296) during follow-up. The overall risk ratio of TM in children with a concurrent diagnosis of PTT was 15.46 (95% CI 6.93-34.47, P < 0.00001).

CONCLUSIONS

The incidence of TM in children is highly variable. Nonetheless, TM is usually bilateral, of the classic type, and remains stable or unchanged at follow-up. Pediatric patients with TM and contributing factors for PTT have an increased risk for PTT; however, there is no evidence to support mandatory US surveillance of children with TM.

Prevalence of testicular microlithiasis in healthy newlywed men trying for first-time pregnancy

OBJECTIVES

To investigate the prevalence of testicular microlithiasis and the relationship between testicular microlithiasis, semen parameters and endocrinological profiles in healthy newlywed men trying for first-time pregnancy.

METHODS

Men visiting Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan, or D Clinic Tokyo, Chiyoda-ku, Tokyo, Japan, for a first-time examination of fertility underwent scrotal examination, semen analysis and blood tests. Testicular volume measured by orchidometer, semen parameters measured by the Makler counting chamber and endocrinological profiles were compared between men with testicular microlithiasis and without testicular microlithiasis. The correlation between sperm concentration and the number of calcifications, and sperm motility and the number of calcifications, were investigated.

RESULTS

Of 739 men, 60 (8.1%) were diagnosed as having testicular microlithiasis. Among them, testicular volume, semen volume and motility were lower than those in the men without testicular microlithiasis. Luteinizing hormone and follicle-stimulating hormone levels were higher in those with than those without testicular microlithiasis. The sperm concentration correlated negatively with the number of calcifications. There was no significant correlation between sperm motility and the number of calcifications.

CONCLUSION

Herein, we report the prevalence of testicular microlithiasis in healthy newlywed men. Furthermore, our findings suggest that semen parameters in men with severe testicular microlithiasis tend to be worse.

Testicular Microlithiasis: Case Report and Current Knowledge

Sonographic evaluation is the gold standard in diagnosing of testicular microlithiasis, the nature of which has raised controversy in opinions regarding its premalignant or benign tendency. Testicular microlithiasis is often an incidental finding on sonographic examination with indications for other disease processes, and it may or may not require additional follow-up. This pathology has raised equal interest among domestic and foreign researchers, and studies have been performed on both adult and pediatric populations, yet there is no standard recommendation for follow-up care of testicular microlithiasis. Isolated testicular microlithiasis and that with additional risk factors may require different approaches to testing and care. In this publication, a case study is reviewed and two approaches to follow-up care of testicular microlithiasis based on the associated risk factors or a lack of thereof are discussed.

Testicular microlithiasis and testicular tumor: a review of the literature

Introduction

There are numerous scientific publications on testicular microlithiasis (TML) detected during ultrasound (US) examination. We wished to update the data.

Methods

PubMed was used to identify original articles published between 1998 and May 2017 describing the association between TML and testicular tumor. Studies were only included if TML was diagnosed by US. Studies were then classified into subgroups according to the following criteria: asymptomatic, symptomatic, infertility, cryptorchidism, family or personal history of testicular cancer, and “no given reason for US”. A Z-Test was used to identify differences within these subgroups. In addition, we identified prospective cohorts of TML patients. Numbers, duration of follow-up, and occurrence of the “testicular tumor” event were recorded for each of them.

Results

One hundred and seventy-five articles were identified, 40 of which were included. Our review has not showed a clear evidence that cryptorchidism associated with TML is a risk factor for testicular tumor. However, there seems to be a correlation between infertility associated with TML and a higher tumor risk. There were not enough studies to confirm a relationship between family or personal history associated with TML and the tumor risk. There was also a correlation with a higher tumor risk for symptomatic associated with TML and “no given reason for US” plus TML groups. However, these groups are assumed to contain bias and caution must be taken regarding conclusions. Regarding the prospective cohort studies, 16 testicular tumors appeared in the follow-up of patients with TML, 13 patients had risk factors.

Conclusion

In cases of TML incidental finding by US with the presence of risk factors (personal history of testicular cancer, testicular atrophy, infertility, cryptorchidism) a consultation with a specialist should be considered. In the absence of risk factors, the occurrence of testicular cancer in patients with TML is similar to the risk of the general population.

The influence of testicular microlithiasis on the outcomes of in vitro fertilisation in a Chinese Han population

To investigate the influence of testicular microlithiasis (TM) on the outcomes of in vitro fertilisation (IVF), we retrospectively reviewed the ultrasonography results of the TM patients who underwent IVF treatment in our hospital. They were classified as classic-TM (CTM) or limited-TM (LTM) comparing with patients without TM (Non-TM). Semen parameters, rates of fertilisation, normal fertilisation, good embryos and clinical pregnancy were analysed. The Non-TM group showed higher percentage of morphologically normal spermatozoa than the CTM or LTM group (4.08 ± 2.07 versus 3.40 ± 2.00 versus 3.04 ± 1.66, p = .003) while the other general semen parameters were comparable. The LTM group showed higher rate of fertilisation than the CTM group (85.10% versus 81.12%, p = .044). Moreover, the rates of normal fertilisation of Non-TM (62.47%) and LTM (66.32%) group were significantly higher than the CTM (58.02%) group (p = .027 and p = .001 respectively). There were 333 embryo transfer cycles in total (including 222 fresh and 111 frozen). The overall clinical pregnancy rate was 54.95%, 58.33% and 64.12% in the group of CTM, LTM and Non-TM respectively. However, no statistically significant difference was obtained (p = .326). Our results suggest that TM may have influence on the IVF outcomes. The extent of microlithiasis correlates inversely with the rates of fertilisation and normal fertilisation.

Testotoxicosis: Report of Two Cases, One with a Novel Mutation in LHCGR Gene

Testotoxicosis is a rare disorder which presents as isosexual peripheral precocious puberty in males. Despite the pattern of autosomal dominant inheritance, sporadic cases also may occur. Due to activating mutation in luteinizing hormone (LH))/choriogonadotropin receptor (LHCGR) gene, early virilization and advancement in bone age are common with increased serum testosterone levels above adult ranges, despite low LH and follicular-stimulating hormone (FSH) levels. There are different treatment regimens, such as combination of bicalutamide (antiandrogen agent) and a third-generation aromatase inhibitor, that are reported to be well-tolerated and successful in slowing bone age advancement and preventing progression of virilization. We report here two patients who presented with peripheral precocious puberty and an activating mutation in the LHCGR gene: one with a family history and previously determined mutation and the other without family history and with a novel mutation (c.830G>T). Combination of bicalutamide+anastrozole was ineffective in slowing pubertal progression and bone age. Short-term results were better with ketoconazole.

Ultrasound demonstration of testicular microlithiasis in pediatric patients: is there an association with testicular germ cell tumors?

BACKGROUND

There is suggestion that testicular microlithiasis predicts risk of testicular malignancy, especially testicular germ cell tumors. This association remains uncertain.

OBJECTIVE

We retrospectively reviewed testicular germ cell tumor occurrence in patients with testicular microlithiasis to assess this association and determined the prevalence of testicular microlithiasis in symptomatic boys.

MATERIALS AND METHODS

This study was IRB and HIPAA compliant. Two-thousand six-hundred twenty-five testicular US exams performed on 2,266 children (younger than 19 years of age) in our institution from 2000 through 2011 were reviewed for presence of testicular microlithiasis and masses. Testicular microlithiasis was defined as presence of five or more testicular microcalcifications on a single US image. Incidence of testicular germ cell tumors was calculated in a group of patients with testicular microlithiasis and in a control group without testicular microlithiasis. Relative risk, odds ratio, 90% and 95%CI were calculated.

RESULTS

Eighty-seven patients out of 2,266 had testicular microlithiasis. One child was found to have both testicular germ cell tumor and testicular microlithiasis. In 2,179 children without testicular microlithiasis, 8 had testicular germ cell tumors. Incidence of testicular microlithiasis was 3.8%. Incidence of testicular germ cell tumors in testicular microlithiasis patients was 1.2%, and 0.38% in non-testicular microlithiasis patients. Relative risk of testicular germ cell tumors in testicular microlithiasis patients vs. non-testicular microlithiasis patients was 3.13 (90%CI: 0.55-17.76; 95%CI: 0.40-24.76), odds ratio 3.16 (90%CI: 0.55-18.32; 95%CI: 0.39-25.5).

CONCLUSION

There is no association between testicular microlithiasis and testicular germ cell tumors. We had hoped to do a meta-analysis, but only two studies had a sufficient case control group of non-testicular microlithiasis patients.