Scrotum and Testicles Flashcards
What should always be evaluated if an intratesticular mass is seen?
The retroperitoneum! Conversely, if retroperitoneal adenopathy is seen in a reproductive-age male, the testicles should always be examined.
Most scrotal masses are __________ relative to normal testicular parechyma.
Hypoechoic
On Doppler, most scrotal masses will have _________ vascularity with ____ diastolic flow, producing a _____ resistence waveform.
- Increased vascularity
- high diastolic flow
- low resistance waveform
What is the most common testicular malignancy?
Prognosis? Epidemiology?
What marker may be elevated, albeit uncommonly?
US appearance?
Name the subtype.
- Seminoma is the most common testicular malignancy.
- It has a favorable prognosis.
- Seminoma typically occurs in middle-aged men.
- Uncommonly, hCG may be elevated.
- The spermatocytic subtype of seminoma occurs in slightly older men (mid 50s) and has an excellent prognosis with orchiectomy only. Tumor markers are not elevated.
What are the nonseminomatous germ cell tumors?
- Embryonal CA
- Teratoma
- Yolk sac (endodermal sinus) tumor
- ChorioCA
- Mixed germ cell tumor
Way to remember: Think of all the tissus that comprise a viable pregnancy: Embryo (also a terror! ~ teratoma) - [and these first two most commonly make up the mixed germ cell tumor], yolk sac, and placenta (chorioCA)
What is the most common Nonsemitomatous germ cell tumor?
Mixed germ cell tumor
What are the most common components of a mixed NSGCT?
Talk about each one.
- Embryonal CA
- Comprised of immature, primitive cells. Forms a hemorrhagic mass with necrosis, and in its pure form is rare. In adults it is typically seen as a component of mixed germ cell tumors. (infantile form is the yolk sac tumor)
- Chemotherapy may result in differentiation into another type of germ cell tumor (eg teratoma)
- Teratoma
- Rare in its pure form in adults, but is seen in 50% of mixed NSGCT. Teratoma is classified as mature, immature, and malignant. In adults, teratomas are usually malignant. In children, teratomas are usually benign, with the mature subtype most commonly seen. AFP or b-hCG may be elevated.
What is the most common testicular tumor of infancy?
What marker is characteristically elevated?
- Yolk sack tumor
- AFP is elevated
What is the US appearance of nonseminomatous (NSGCT) germ cell tumors?
NSGCT epidemiology? Local invasion into what structures is common?
- A heterogeneous testicular mass that contains solid and cystic components and coarse calcification is a typical appearance for an NSGCT. It is not possible to distinguish the various subtypes of NSGCT on sonography.
- NSGCT generally occur in younger patients compared to seminomas, typically in young men in their 20s and 30s. NSGCT tend to be more aggressive than seminomas. Local invasion into the tunica albuginea and visceral metastases are common.
What is the most aggressive testicular tumor?
It is a malignant tumor of what cells lines?
Where doe in like to metastasize to via what route?
What marker is characteristically elevated? What may result?
- Choriocarcinoma
- Malignant tumor cells of syncytio- and cytotrophoblasts
- Spreads early hematogenously to brain and lung and mets tend to be hemorrhagic
- bHCG is elevated (a-subunit of hCG is similar to that of FSH, LH and TSH)
- Therefore, may lead to hyperthyroidism or gynocomastia
What is a burnt-out germ cell tumor?
Characteristic US appearance?
Treatment?
- Burnt-out germ cell tumor is a primary testicular neoplasm that is no longer viable in the testicle even though there is often viable metastatic disease, especially retroperitoneal.
- In the testicle, focal calcification with shadowing is characteristic. A mass may or may not be present.
- Treatment is orchiectomy in addition to systemic chemotherapy.
What is the name for multiple punctate testicular calcifications?
What is considered the limited form?
What characteristic appearance may be seen on US?
- Microlithiasis
- At least five microcalcifications must be present per image to be called microlithiasis. If there are fewer than five microcalcifications the term limited microlithiasis is used.
- Microlithiasis can produce a starry sky appearance if calcifications are numerous.
- In the liver, hepatitis can cause a starry sky appearance due to increased echogenicity of the portal triads.
What is the most common metastases to the testis and why?
Present in what age group and which side?
Possible US appearance?
- The most common metastases to the testicles are leukemia and lymphoma
- Usually of diffuse large B-cell type
- The relevant chemotherapeutic agents do not cross the blood-testis barrier.
- Hematologic malignancies typically present in older patients (most common cause of testicular mass in males > 60yo) and tend to be bilateral.
- May be infiltrative with diffuse testicular enlargement.
What is an epidermoid tumor and how does it appear on testicular US?
Management?
- An epidermoid is a keratin-filled cyst with a distinctive onion-ring appearance of concentric alternating rings of hypo- and hyperechogenicity.
- If suspected, local excision is performed instead of the standard orchiectomy typically performed for presumed malignant masses.
What are the benign testicular tumor mimics?
-
Congenital adrenal rests are embryologic remnants of adrenal tissue trapped within the testis. These are typically seen in newborns with congenital adrenal hyperplasia.
- Adrenal rests appear as bilateral hypoechoic masses and classically enlarge with ACTH exposure.
- Polyorchidism/supernumerary testis: An extra testicle has an identical imaging appearance to the normal testicular parenchyma.
- Extranumerary testes carry a slightly increased risk of torsion and testicular cancNexter.