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Myxoid liposarcoma of the right spermatic cord in a 73year-old man. A, Sagittal extended field-of-view image of the left hemiscrotum showing the testis (T) and a solid heterogeneous mass (arrows) separate from it. The lesion had a markedly hyperintense signal on T2-weighted MRI, suggesting a cyst (not shown). However, it was clearly solid on sonography, with internal vessels visible on color Doppler imaging (B).
Source publication
In this pictorial essay, we review the sonographic and other imaging findings of paratesticular masses in correlation with the pathologic findings. The examples include benign and malignant tumors and also non-neoplastic mass lesions of the paratesticular structures. Diagnostic sonographic findings of these mass lesions as well as correlative findi...
Citations
... [6] Color Doppler helps to demonstrate the vascularity and to differentiate testicular from paratesticular region. [7] USG of scrotum has been mentioned to distinguish testis and scrotal mass with a sensitivity of more than 95%. [8] To evaluate the location, size, and metastasis, CT and magnetic resonance imaging (MRI) are reliable modalities; however, they cannot be used for the confirmation of diagnosis. ...
A BSTRACT
Paratesticular embryonal rhabdomyosarcoma (RMS) is a very rare and aggressive mesenchymal tumor. It is usually seen in children and adolescents presenting as a painless intrascrotal mass, localized in the paratesticular region. Hereby, we report two cases of paratesticular embryonal RMS in adults. One case was clinically suspected to be a testicular abscess, whereas the other presented with testicular swelling and lung metastasis. Localized forms have a good prognosis, whereas tumors presenting with metastases show a poor outcome. A treatment based on surgery and chemotherapy yields good results. Sperm cryopreservation and endocrine follow-up improve the overall survival and quality of life of these patients.
... All these can be answered with excellent accuracy using B-Mode US, which has been p offer nearly 100% sensitivity for the detection of lesions in the scrotal a Additionally, color and power Doppler (CD and PD) techniques can be appr optimized such that they are rendered sensitive to low-velocity flow such as tha in the scrotum, thus assessing the presence and pattern of lesional vascularity. H the specificity if US is lower (around 70% to 90%) in the characterization of PTs, e using Doppler techniques, and a definite diagnosis is not always possible [6]. ...
... Once a lesion is detected during scrotal US, a physician needs to address the following questions: (a) is the lesion's epicenter inside or outside of the testicular parenchyma, thus determining whether it is intra-or paratesticular; (b) which particular organ of the paratesticular space is affected: the epididymis, the spermatic cord, or the fascial coverings; and (c) is the lesion cystic or solid, the determination of which will aid proper differential diagnosis [4]. All these questions can be answered with excellent accuracy using B-Mode US, which has been proven to offer nearly 100% sensitivity for the detection of lesions in the scrotal area [6,7]. Additionally, color and power Doppler (CD and PD) techniques can be appropriately optimized such that they are rendered sensitive to low-velocity flow such as that present in the scrotum, thus assessing the presence and pattern of lesional vascularity. ...
... Additionally, color and power Doppler (CD and PD) techniques can be appropriately optimized such that they are rendered sensitive to low-velocity flow such as that present in the scrotum, thus assessing the presence and pattern of lesional vascularity. However, the specificity if US is lower (around 70% to 90%) in the characterization of PTs, even when using Doppler techniques, and a definite diagnosis is not always possible [6]. ...
Background: Paratesticular tumors (PTs) are very uncommon, accounting for almost 5% of intrascrotal tumors. Of these, adenomatoid tumors (ATs) represent about 30% and most frequently arise in the tail of the epididymis. Ultrasound (US) examination is the first-choice imaging method employed for the evaluation of the scrotum. Unfortunately, there are no specific US-imaging features useful for distinguishing an AT from a malignant lesion. To increase diagnostic accuracy and confidence, new sonographic techniques have incorporated real-time tissue elastography (RTE) under the assumption that malignant lesions are “harder” than benign lesions. Case report: In our paper, we describe a very rare case of a 60-year-old patient with a giant paratesticular mass mimicking malignancy when examined using RTE, i.e., it was stiffer than the surrounding tissue (a hard pattern), which, upon histologic examination, was identified as an AT. Discussion: Our case underscores that there is also a significant overlap between different types of scrotal lesions when RTE is used for examination. Thus, if a PT is found, the imaging approach should always be supplemented with more definitive diagnostic methods, such as FNAC or FNAB, which are the only diagnostic methods capable of leading to a certain diagnosis. Conclusions: Alongside underlining the importance of pre-operative imaging for making correct diagnoses and selecting the correct therapy, we wish to draw our readers’ attention to this report in order to demonstrate the clinical implications of a giant AT presenting as stiff lesions when examined using SE.
... However, ultrasound can identify lesions in almost all cases, accurately estimate their scope and relationship with adjacent tissues, and diagnose some common benign scrotal lesions (20). The study of Mustafa S et al. shows that in most cases, malignant and benign paratesticular masses can be distinguished by ultrasound, MRI or combination, but it should also be noted that the imaging manifestations of benign and malignant tumors may overlap (21). Shaodong Qiu et al. proposed that ultrasound elastography is expected to become a new examination method for clinical diagnosis of scrotal diseases (22). ...
Background:
Epididymal leiomyosarcoma is an extremely rare tumor. In this study, we describe the sonographic features of this uncommon tumor.
Methods:
A case of epididymal leiomyosarcoma diagnosed at our institute was retrospectively analyzed. Ultrasonic images, noted clinical manifestations, treatment procedures, and pathology results were collected for this patient. The same information was collected from a systematic literature search on epididymal leiomyosarcoma, including the PUBMED, Web of Science and Google Scholar databases.
Results:
The literature search resulted in 12 articles; we were able to extract data from 13 cases of epididymal leiomyosarcomatosis. The median patient age was 66 (35-78) years, and the average tumor diameter was 2-7 cm. All patients had unilateral epididymal involvement. The lesions were all solid, irregular-shaped in almost half of the cases, featured clear borders in six cases, and had unclear borders in four cases. The internal echogenicity was heterogeneous in the majority of lesions: six cases were hypoechoic (7/11) and three cases moderately echoic (3/10). Information on blood flow within the mass was provided in four cases, but all were noted with significant vascularity. Surrounding tissue invasion was discussed in 11 cases, with 4 featuring peripheral invasion or metastasis.
Conclusion:
Epididymal Leiomyosarcoma demonstrates sonographic characteristics common to many malignant tumors, such as increased density, irregular shape, heterogeneous internal echogenicity, and hypervascular. Ultrasonography is helpful to differentiate benign epididymal lesions, and can provide some reference for clinical diagnosis and treatment. However, compared with other malignant tumors of the epididymis, it has no characteristic sonographic features,and pathological confirmation is required.
... Differential diagnosis of a paratesticular mass presents a significant diagnostic challenge given the rarity of polyorchidism and the wide spectrum of potential neoplastic and non-neoplastic lesions. 2 Importantly, malignant neoplasms such as rhabdomyosarcomas, leiomyosarcomas and liposarcomas must be considered in context of the patient's age and ruled out. 3 Moreover, polyorchidism itself carries an increased risk of testicular malignancy, with cryptorchidism the likely most important risk factor for malignancy. 1 This is highlighted in our case whereby the left supernumerary testis appears to have been missed during childhood, both on clinical examination and surgical exploration. This is most likely due to its small size and rarity. ...
... On ultrasonography, the supernumerary testis is often smaller in size and hypoechoic to the normal testis, which it may or may not be connected to, and on Doppler the vascularity is often less. 3 The mediastinum testis and shared epididymis may be shown, or a supernumerary epididymis may be detected. 3 With a sensitivity of nearly 100% for lesions detected in the scrotal area, and a specificity of 70-90% depending on the location and characteristics of the lesion, US is the method of choice and in most cases is diagnostic. ...
... 3 The mediastinum testis and shared epididymis may be shown, or a supernumerary epididymis may be detected. 3 With a sensitivity of nearly 100% for lesions detected in the scrotal area, and a specificity of 70-90% depending on the location and characteristics of the lesion, US is the method of choice and in most cases is diagnostic. [2][3][4] However in complicated cases such as ours, where the patient had undergone orchidopexy for left-sided cryptorchidism in childhood, MRI should be utilised for definitive tissue characterisation. ...
Polyorchidism is a rare congenital anomaly which describes the presence of more than two intra- or extra scrotal testes. Typically, the supernumerary testis is found incidentally during surgery for another condition but may present clinically as a painless paratesticular mass necessitating a radiological diagnosis. Polyorchidism carries an increased risk of testicular malignancy, with cryptorchidism the likely most important risk factor. Given, however, that the supernumerary testis likely contributes a reproductive function, surgical removal and definitive histopathological diagnosis is not always appropriate. We present a radiologically diagnosed supernumerary testis in a 40-year-old male with a history of surgically managed cryptorchidism in childhood.
... Lipomas are the most common SC tumor, accounting for 70% of cases (55). At US, lipomas are well-defined homogeneous hyperechoic masses that are lateral or inferior to the cord (31,57). They may contain echogenic linear interfaces and are usually nonvascular at Doppler US (Fig 18). ...
... They demonstrate high signal intensity at T1-weighted MRI and do not enhance after administration of intravenous contrast material (58). Although lipomas can be mistaken for fat-containing inguinal hernias because of shared radiologic findings, unlike lipomas, hernias are usually anteromedial to the cord (10,57). In addition, during the Valsalva maneuver, the contents of an inguinal hernia move anterior to the SC, which would not occur with a lipoma (7). ...
... Adenomatoid tumors (ie, hamartomatous benign tumors arising from mesothelial cells) are the second most common type of paratesticular neoplasms (57). Although they occur most commonly in the epididymis, they can also occur as an SC tumor (59). ...
A wide range of benign and malignant processes can affect the spermatic cord (SC). Familiarity with and recognition of the characteristic imaging features of these entities are imperative for accurate diagnosis and optimal clinical care. While some SC diseases are self-limiting, others can result in infertility and potentially life-threatening infection or bleeding if they are left untreated. Therefore, correct diagnosis is important for life-saving treatment and preservation of fertility. Disorders including anomalies of the vas deferens and the processus vaginalis, arterial and venous diseases (torsion of the SC and varicoceles), infection, trauma, and neoplasms are the most pertinent entities with which radiologists should be familiar when assessing the SC. Knowing what to expect in a patient who has undergone SC interventions is imperative. US has a fundamental role in the initial examination of patients who present with symptoms that indicate abnormalities of the SC, such as suspected posttraumatic testicular retraction or SC torsion. Other imaging techniques including abdominal and pelvic MRI and CT have their own importance. For correct interpretation of the findings and to establish an accurate diagnosis, it is crucial to have a thorough knowledge of the anatomy, the utility and limitations of various imaging modalities, optimal imaging and scanning techniques, and the imaging features of various benign and malignant pathologic conditions that can involve the SC. Online supplemental material is available for this article. ©RSNA, 2022.
... Ultrasonography has excellent sensitivity and specificity to assess any lesion in the scrotum. It is easy accessibility, and safe application makes it the initial exam of choice [10]. Ultrasound can differentiate between testicular and para-testicular masses with a sensitivity of 95% [11]. ...
Background
Primary soft tissue sarcomas contribute to only 2% of all malignancies arising from the male genitourinary tract. Leiomyosarcoma (LMS) is a malignant soft tissue neoplasm which originates from the mesenchyme and has a characteristic smooth muscle differentiation. Usually, it presents as a painless, firm, slow-growing unilateral scrotal mass. Investigations include imaging, tumor markers, and histopathology.
Case presentation
A 65-year-old gentleman known diabetic and beta-thalassemic trait was referred to the Urology OPD at Letterkenny University Hospital. His presenting complaint was a left groin lump that appeared 1 year ago and was growing larger in size gradually. According to the patient, his lump was slightly painful (localized) initially that later became painless. He did not report any testicular trauma/infection or UTI. There was no significant history of malignancies running through his family. Clinical examination revealed a soft and lax abdomen, normal testes. There was a non-tender 2cm x 2cm well-circumscribed, mobile, firm to cystic irreducible left inguinoscrotal mass and appeared to be attached to the spermatic cord. Cough impulse was indiscernible. Ultrasound left groin showed 1.8 cm transverse x 1.4 cm AP x 1.9 cm sagittal) well-circumscribed ovoid nodular subcutaneous lesion present in the upper left inguinal area just lateral to the left pubic tubercle that appeared solid with heterogeneous internal echotexture and no internal calcification. Some internal vascularity is demonstrated with color Doppler assessment.
Conclusion
Because of its rareness, LMS represents a management conundrum. There is no standard protocol for treatment. We present a case and discuss the available evidence from the literature to date to help identify LMS of the spermatic cord that is highly unusual.
... Ultrasonography has an excellent sensitivity and speci city to assess any lesion in the scrotum. It's easy accessibility and safe application make it the initial exam of choice [10]. Ultrasound can differentiate between testicular and para-testicular masses with a sensitivity of 95% [11]. ...
Background:
Primary soft tissue sarcomas contribute to only 2% of all malignancies arising from the male genitourinary tract. Leiomyosarcoma (LMS) is a malignant soft tissue neoplasm which originates from the mesenchyme and has a characteristic smooth muscle differentiation. Usually, it presents as a painless, firm, slow growing unilateral scrotal mass. Investigations include imaging, tumour markers and histopathology.
Case Presentation:
A 65 year old gentleman known Diabetic and Beta-thalassemic trait was referred to Urology OPD at Letterkenny University Hospital. His presenting complaint was left groin lump which appeared one year ago and was growing larger in size gradually. According to the patient his lump was slightly painful(localized) initially, that later became painless. He did not report any testicular trauma/infection or UTI. There was no significant history of malignancies running through his family. Clinical examination revealed soft and lax abdomen, normal testes. There was a non-tender 2cm x 2cm well circumscribed, mobile, firm to cystic irrudicible left inguinoscrotal mass, appeared to be attached to the spermatic cord. Cough impulse was indiscernible. Ultrasound left groin showed 1.8 cm transverse x 1.4 cm AP x 1.9 cm sagittal) well-circumscribed ovoid nodular subcutaneous lesion present in the upper left inguinal area just lateral to the left pubic tubercle. That appeared solid with heterogeneous internal echotexture. No internal calcification. Some internal vascularity is demonstrated with colour Doppler assessment.
Conclusion:
Because of its rareness, LMS represents a management conundrum. There is no standard protocol for treatment. We present a case and discuss the available evidence from the literature to date to help identifying LMS of spermatic cord that’s highly unusual.
... These tumors are often benign, including mainly lipoma, adenomatoid tumor and leiomyoma. Malignancies, including sarcomas, lymphomas and metastases may also be seen [79,80,133,134,[174][175][176][177][178][179]. ...
... Lipoma is the commonest solid paratesticular neoplasm, usually involving the spermatic cord. It presents with nonspecific US findings, mostly hyperechoic and differential diagnosis from hernias and sarcomas may be difficult [80,174,187]. Adenomatoid tumor represents the second most common paratesticular neoplasm, often arising from the epididymal tail. However, the tumor may involve the spermatic cord or the tunica albuginea, and may extent intratesticularly. ...
... However, the tumor may involve the spermatic cord or the tunica albuginea, and may extent intratesticularly. US features are indeterminate, including a small, well-defined, homogeneous mass, of variable echogenicity, without avid vascularization (Fig. 25) [80,174,180,181,187]. Leiomyoma represents the second commonest epididymal tumor. ...
Conventional US is the primary imaging modality for the evaluation of the scrotum, due to its high resolution, availability, cost-effectiveness and absence of ionizing radiation. Grayscale and color Doppler US provide a comprehensive assessment of scrotal diseases. The technique represents the mainstay for imaging of acute scrotum. US is highly accurate in the detection, localization and characterization of scrotal masses.
Multiparametric US, including conventional US, contrast-enhanced US and tissue elastography has improved the diagnostic performance of the technique in the assessment of testicular diseases. MRI represents a valuable supplemental imaging tool for the investigation of scrotal pathology, mainly recommended in cases of indeterminate US findings.
Recommendations recently issued by the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) refer to the use of scrotal sonography for the evaluation of pathologic entities, including testicular microlithiasis, small, non-palpable incidentally detected testicular masses, varicocele and scrotal trauma.
In this review, the technical specifications for scrotal US and the normal sonographic findings are presented. Grayscale and color Doppler US findings of common acute scrotal diseases and scrotal masses are discussed. The complimentary role of multiparametric US and scrotal MRI is addressed. ESUR-SPIWG’s guidelines are also reviewed.
... Az irodalom jelenleg a paratesticularis teriméket három csoportba osztja: jóindulatú, illetve rosszindulatú daganatok, valamint nem daganatos eltérések [10]. Klinikai és képalkotó szempontokat figyelembe véve kidolgoztunk egy algoritmust, mely jobban áttekinthetővé teszi ezen ritka eltéréseket, és segíthet a klinikai döntéshozatalban, a betegút megtervezésében (1. ...
... A leggyakoribb malignus paratesticularis megbetegedések közé a különböző sarcomák tartoznak, úgymint a liposarcoma, a leiomyosarcoma és a rhabdomyosarcoma, melyek közül az utóbbi fiatalkorban, az első két évtizedben fordul elő [15]. Ha a rhabdomyosarcomát korán fedezik fel, a képalkotó vizsgálatok során homogén megjelenésű lehet, de típusosan nagy kiterjedésű, heterogén, cysticus és necroticus részeket egyaránt tartalmaz [10]. ...
Összefoglaló. A scrotum képalkotó vizsgálóeljárásai közül elsőnek választandó az ultrahang, mivel könnyen hozzáférhető, szenzitivitása és specificitása magas. Szerepe kiemelendő mind az intratesticularis eltérések differenciáldiagnózisában, mind pedig a kevésbé ismert paratesticularis eltérések esetében. Az urológiai ambulancián egy 56 éves férfi jelentkezett kivizsgálásra tapintható terime miatt. Ultrahangvizsgálattal paratesticularis elváltozás látszódott, mely a vizsgálat során az inguinalis csatorna irányába többször elmozdult. A laesio dignitása nem volt meghatározható, ezért műtéti eltávolításra került sor. A szövettani vizsgálat a férfiak körében ritkán előforduló angiomyofibroblastoma diagnózisát véleményezte. A paratesticularis elváltozások ugyan ritkán fordulnak elő, de a gyakoribb entitások és azok ultrahangos sajátosságainak ismerete elengedhetetlen a terápia tervezése szempontjából. Orv Hetil. 2021; 162(34): 1376–1382.
Summary. Ultrasonography is the basic imaging technique for the evaluation of testicular structures because it is easily accessible and has high sensitivity and specificity. It plays a significant role in the differential diagnosis of intratesticular changes, in addition, its role should be emphasised in rare paratesticular abnormalities. A 56-year-old male presented in the urology department complaining of a palpable inguinal mass and was referred to ultrasonography for further evaluation. A scrotal ultrasound was performed, and it described a mobile paratesticular mass without any specific characterizations. Therefore the lesion was removed, and the histological analysis established the diagnosis of angiomyofibroblastoma. Paratesticular lesions are rare, but it is essential to know the frequent abnormalities and the corresponding ultrasound findings for planning of treatment. Orv Hetil. 2021; 162(34): 1376–1382.
... These include the following: (i) the appendix epididymis located in the superior part of the epididymis, being a remnant of mesonephric (Wolffian) duct and found in 34% of testes in postmortem studies, (ii) the appendix testis (hydatid of Morgagni), situated in the testicular surface, adjacent to the epididymal head, found in 92% of testes in postmortem studies (Figure 1), (iii) the vas aberrans or 'organ of Haller' is an appendage originating from the body of epididymis and (iv) the paradidymis or 'organ of Giraldes' connected to the vas deferens. [11][12][13][14] Testicular and epididymal appendages may be solid or cystic and have a variety of shapes including rounded, ovoid or pedunculated. 12 The epididymis is located in the posterior aspect of the testis, formed by the efferent ductules originating from the testicular parenchyma and forming its head, body and tail. ...
... There is scrotal wall thickening (short arrows) F I G U R E 7 A longitudinal image through the left scrotal sac, demonstrating a normal testis (star) with a hydrocoele surrounding the upper aspect of the testis, and with an irregular walled abscess within the thickened epididymis and with echogenic debris present (arrows) F I G U R E 8 A longitudinal image through the left scrotal sac, with the inferior aspect of the testis (star) adjacent to a thickened heterogenous epididymal tail (arrows) consistent with acute epididymitis potentially with calcifications. 7,11 Doppler techniques only rarely show internal blood flow signals. Hydrocele can be seen in almost 50% of patients, while a third report a previous episode of epididymo-orchitis. ...
... Colour Doppler US may find some blood flow signals but this is an unreliable diagnostic criterion. 6,11 In terms of size, leiomyomas usually range between <1 and 3 cm. 7 Angioleiomyoma is a similar histologic type of tumour, with the difference of containing small vessels and multiple ectatic vessels. ...
Background
Ultrasound (US) is the primary modality for the investigation of scrotal pathology, including both intra‐ and para‐testicular abnormalities.
Objective
To describe the abnormalities of the para‐testicular space.
Materials/Methods
The para‐testicular space contains the epididymis, spermatic cord and the tunica vaginalis cavity and is affected by a variety of inflammatory or tumoral entities. Differential diagnosis based on US criteria is frequently problematic, as the findings are non‐specific.
Results
Some general rules apply: i) unlike testicular lesions, extra‐testicular entities are usually benign in the adult ii) the first steps to accurate diagnosis include careful localization of the lesion and assessment of its consistency (solid or cystic) iii) Magnetic resonance imaging can be useful for further tissue characterization of lesions suspected to contain fat, but surgical biopsy will often provide the definite diagnosis. Contrast‐enhanced ultrasound (CEUS) has been applied with limited experience indicating a narrow role, primarily for the differential diagnosis of echogenic cystic entities and the delineation of a necrotic abscess from a solid neoplasm.
Discussion
The various abnormalities are discussed and illustrated.
Conclusion
This manuscript summarizes the literature on para‐testicular lesions and the value of US in diagnosis.
