Scrotal Mass

Pathway

Images

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1		Testicular Cyst Image 1 (Ultrasound): Left testicular cyst with no discernable wall or flow.
2		Testicular Tumour Image 2 (Ultrasound): Solid and cystic lesion with thick walls and marked vascularity in some areas. The appearances are consistent with a tumour.
3a		Testicular Tumour Image 3a: Orchidectomy specimen showing complete replacement of the normal testicular parenchyma with the classical "cut-potato" appearance of a seminoma. The tunica albuginea is intact.
3b		Image 3b (H&E, x2.5): Histological section of a seminoma showing groups of malignant cells with large nuclei and prominent nucleoli. There are also intervening fibrous bands with an infiltrate of lymphocytes and plasma cells.
4a		Testicular Tumour Image 4a (H&E, x2.5): Orchidectomy specimen showing a teratoma with areas of cyst formation and haemorrhage.
4b		Image 4b (H&E, x2.5): Histological section of a teratoma (non-seminomatous germ cell tumour) showing hyaline cartilage and islands of columnar epithelium.
5		Scrotal Abscess Image 5 (Ultrasound): A central mass lesion is located superficially and in the midline towards the inferior pole of the scrotum. It has a low echogenic rim but contains echogenic material with no discernable flow within the lesion. There is inflammation of the surrounding tissues.

Teaching Points

Teaching Points

• Ultrasound is the preferred imaging modality to evaluate a scrotal mass 1-3
• Ultrasound can be used to differentiate between intra and extra testicular masses. It is also useful for differentiating solid from cystic masses 4
• A painless solid testicular mass is pathognomonic for testicular tumour, 1 though a proportion present with pain
  • 95% of testicular malignancies are germ cell tumours 5
  • In older men over 60, lymphoma is the most common testicular malignancy 6
• A mass in the body of the testicle is likely malignant until proven otherwise and is an indication for urgent urology referral

References

References

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

1. National Comprehensive Cancer Network. NCCN Clinical practice guidelines in oncology (NCCN guidelines). Testicular cancer. 2016. (Guideline). View the reference
2. Albers P, Albrecht W, Algaba F, Bokemeyer C, Cohn-Cedermark G, Fizazi K, et al. EAU Guidelines. Edn. presented at the EAU Annual Congress Copenhagen. European Association of Urology; 2018. (Guideline). View the reference
3. Yacoub JH, Oto A, Allen BC, Coakley FV, Friedman B, Hartman MS, et al. ACR appropriateness criteria staging of testicular malignancy. J Am Coll Radiol. 2016;13(10):1203-9. (Guideline). View the reference
4. Coursey Moreno C, Small WC, Camacho JC, Master V, Kokabi N, Lewis M, et al. Testicular tumors: what radiologists need to know--differential diagnosis, staging, and management. Radiographics. 2015;35(2):400-15. (Review article). View the reference
5. Baird DC, Meyers GJ, Hu JS. Testicular cancer: diagnosis and treatment. Am Fam Physician. 2018;97(4):261-8. (Review article). View the reference
6. Zucca E, Roggero E, Bertoni F, Cavalli F. Primary extranodal non-Hodgkin's lymphomas. Part 1: Gastrointestinal, cutaneous and genitourinary lymphomas. Ann Oncol. 1997;8(8):727-37. (Review article). View the reference
7. Adeyoju AB, Collins GN, Pollard AJ, Liaw J, Brooman PJ, O'Reilly PH. A prospective evaluation of scrotal ultrasonography in clinical practice. BJU Int. 2000;86(1):87-8. (Level II evidence). View the reference
8. Rifkin MD, Kurtz AB, Pasto ME, Goldberg BB. Diagnostic capabilities of high-resolution scrotal ultrasonography: prospective evaluation. J Ultrasound Med. 1985;4(1):13-9. (Level II evidence). View the reference
9. Kim W, Rosen MA, Langer JE, Banner MP, Siegelman ES, Ramchandani P. US MR imaging correlation in pathologic conditions of the scrotum. Radiographics. 2007;27(5):1239-53. (Review article). View the reference
10. Tallen G, Hernaiz Driever P, Degenhardt P, Henze G, Riebel T. High reliability of scrotal ultrasonography in the management of childhood primary testicular neoplasms. Klin Padiatr. 2011;223(3):131-7. (Level III evidence). View the reference
11. Guthrie JA, Fowler RC. Ultrasound diagnosis of testicular tumours presenting as epididymal disease. Clin Radiol. 1992;46(6):397-400. (Level II evidence). View the reference
12. Yagil Y, Naroditsky I, Milhem J, Leiba R, Leiderman M, Badaan S, et al. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. J Ultrasound Med. 2010;29(1):11-21. (Level II evidence). View the reference
13. Shaida N, Berman LH. Percutaneous testicular biopsy for indeterminate testicular lesions. The British Journal of Radiology. 2012;85(Spec Iss 1):S54-S8. (Review article). View the reference
14. Epstein BE, Order SE, Zinreich ES. Staging, treatment, and results in testicular seminoma. A 12-year report. Cancer. 1990;65(3):405-11. (Level III evidence). View the reference
15. Leibovitch L, Foster RS, Kopecky KK, Donohue JP. Improved accuracy of computerized tomography based clinical staging in low stage nonseminomatous germ cell cancer using size criteria of retroperitoneal lymph nodes. J Urol. 1995;154(5):1759-63. (Level II evidence). View the reference
16. Husband JE, Barrett A, Peckham MJ. Evaluation of computed tomography in the management of testicular teratoma. Br J Urol. 1981;53(2):179-83. (Level III evidence). View the reference
17. Richie JP, Garnick MB, Finberg H. Computerized tomography: how accurate for abdominal staging of testis tumors? J Urol. 1982;127(4):715-7. (Level II evidence). View the reference
18. Hilton S, Herr HW, Teitcher JB, Begg CB, Castellino RA. CT detection of retroperitoneal lymph node metastases in patients with clinical stage I testicular nonseminomatous germ cell cancer: assessment of size and distribution criteria. AJR Am J Roentgenol. 1997;169(2):521-5. (Level II evidence). View the reference
19. Strohmeyer T, Geiser M, Ackermann R, Mumperow E, Hartmann M. Value of computed tomography in the staging of testicular tumors. Urol Int. 1988;43(4):198-200. (Level II-III evidence). View the reference
20. Thomas JL, Bernardino ME, Bracken RB. Staging of testicular carcinoma: comparison of CT and lymphangiography. AJR Am J Roentgenol. 1981;137(5):991-6. (Level II-III evidence). View the reference
21. Sohaib SA, Koh DM, Barbachano Y, Parikh J, Husband JE, Dearnaley DP, et al. Prospective assessment of MRI for imaging retroperitoneal metastases from testicular germ cell tumours. Clin Radiol. 2009;64(4):362-7. (Level II-III evidence). View the reference
22. Kok HK, Leong S, Torreggiani WC. Is magnetic resonance imaging comparable with computed tomography in the diagnosis of retroperitoneal metastasis in patients with testicular cancer? Can Assoc Radiol J. 2014;65(3):196-8. (Review article). View the reference
23. DeWitt ME, Greene DJ, Gill B, Nyame Y, Haywood S, Sabanegh E, Jr. Isolated right varicocele and incidence of associated cancer. Urology. 2018 (Level II evidence). View the reference
24. Skinner DG, Colvin RB, Vermillion CD, Pfister RC, Leadbetter WF. Diagnosis and management of renal cell carcinoma. A clinical and pathologic study of 309 cases. Cancer. 1971;28(5):1165-77. (Level II evidence). View the reference
25. El-Saeity NS, Sidhu PS. "Scrotal varicocele, exclude a renal tumour". Is this evidence based? Clin Radiol. 2006;61(7):593-9. (Review article). View the reference
26. Tyloch JF, Wieczorek AP. Standards for scrotal ultrasonography. Journal of Ultrasonography. 2016;16(67):391-403. (Review article). View the reference

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