Testicular Seminoma and Testicular Microlithiasis

Testicular mass in 40M • Xray of the Week

This 40 year old male presented with a large tender right testicular mass and a left neck supraclavicular mass. What is the diagnosis?

A: Ultrasound demonstrating a large right testicular heterogeneous mass.

B: Ultrasound demonstrating testicular microlithiasis in the otherwise normal left testis.

C: CT demonstrating left para-aortic lymphadenopathy.

D: Ultrasound demonstrating a large biopsy-proven metastatic node in the left side of neck.

Testicular seminoma, a type of germ cell tumor, is the most common testicular neoplasm, accounting for nearly half of all cases. Undescended testis has a 10-40 fold increase in the risk for seminoma, and there is also increased risk in the contralateral testis, even if it is within the scrotum. Presentation with distant disease is rare as most cases present with a painless mass confined to the testis (stage 1). Ultrasound findings are a hypoechoic intratesticular mass, usually confined within the tunica albuginea. Retroperitoneal lymphadenopathy (stage 2) is seen in 15% at presentation, while distant metastatic disease (stage 3) is only present in about 5% of patients. Treatment is orchiectomy, radiation therapy of the nodal disease, and chemotherapy. Prognosis is excellent with a greater than 90% five year survival.

Testicular microlithiasis is present in about 50% of men with a germ cell tumor. (1,2) However, the association with testicular microlithiasis is very controversial. Some authorities recommend screening ultrasound on all patients with the condition (1). However, recent articles concluded that screening is necessary in only a select high risk population with the following characteristics: a personal history of germ cell tumor, first degree relative with testicular cancer, undescended or maldescended testis, infertility, or testicular atrophy. They state that patients with testicular microlithiasis and no risk factors should be screened the as the rest of the population, with monthly testicular self exam (2,3).

References:

1. Richenberg J, Belfield J, Ramchandani P, et al. Testicular microlithiasis imaging and follow-up: guidelines of the ESUR scrotal imaging subcommittee. Eur Radiol. 2015;25(2):323-330. doi:10.1007/s00330-014-3437-x

2. Shanmugasundaram R, Singh JC, Kekre NS. Testicular microlithiasis: Is there an agreed protocol?. Indian J Urol. 2007;23(3):234-239. doi:10.4103/0970-1591.33442

3. Winter TC, Kim B, Lowrance WT, Middleton WD. Testicular Microlithiasis: What Should You Recommend?. AJR Am J Roentgenol. 2016;206(6):1164-1169. doi:10.2214/AJR.15.15226

Kevin Rice, MD is a radiologist with Renaissance Imaging Medical Associates. He has held many leadership positions including Radiology Department Chair and Chief of Staff. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field.

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