and Pilar González-Peramato2
KeywordsTesticular neoplasmsTesticular metastatic tumorsTesticular metastatic neuroblastomaTesticular metastatic prostate adenocarcinomaTesticular metastatic lung carcinomaTesticular metastatic urothelial carcinomaTesticular leukemia infiltration
Most of the secondary tumors of the testicle appear throughout the evolution of a well-known tumor with disseminated disease, so that its diagnosis does not present difficulties. In childhood, it is not uncommon to observe metastases of neuroblastoma, rhabdomyosarcoma, and leukemias. In the adult, testicular metastases most frequently come from primary tumors of the prostate, gastrointestinal tract, kidney, lung, melanoma, and urinary bladder.
In most cases, the histological pattern resembles that of the original tumor, but there are situations in which tumor growth raises several differential diagnoses. There are three tumors that can simulate primary testicular tumors. The carcinomas of the kidney, urinary bladder, and prostate can simulate a carcinoma of the rete testis, when they metastasize in it, or an intertubular germ cell tumor, since this type of growth is common as it also occurs with lymphomas. If the tumor cells of any carcinoma undergo cytoplasmic vacuolization, they can simulate a Sertoli cell tumor. But still more, it is estimated that a palpable testicular mass associated or not with hydrocele may be the first manifestation of a hidden tumor in nothing less than 10% of tumors. Metastases of the following tumors have been chosen as examples: adrenal neuroblastoma, acute lymphoblastic leukemia, prostate carcinoma (conventional and neuroendocrine), lung adenocarcinoma, adenocarcinoma of the colon, and urothelial carcinoma. The interest lies not only on some peculiarities of some cases but these highlight the value of immunohistochemistry in every case.
Case 126. Testicular and Spermatic Cord Metastasis from Adrenal Neuroblastoma
Clinical case. A 5-year-old boy diagnosed of neuroblastoma of the left adrenal gland with bone metastases. He developed a nodular enlargement of the left testicle and the spermatic cord that required radical orchiectomy.
Comments. Involvement of the testicle and paratesticular structures in neuroblastoma is not frequent; however, it is the childhood tumor that metastasizes in the testicle more frequently. Paratesticular is more frequent than testicular involvement. In most cases, these patients have an advanced infradiaphragmatic disease. Although testicular involvement may manifest as a primary tumor several years after a successful treatment of neuroblastoma, it is considered a recurrence. The most plausible route is retrograde lymphatic dissemination from the abdominal mass. In this case, the retrograde venous route seems to be the most probable one. The potential origin of some paratesticular neuroblastomas is speculated to be the paratesticular sympathic remnants.
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Case 127. Testicular Relapse in Acute Lymphoblastic Leukemia
Clinical case. A 13-year-old patient diagnosed with lymphoblastic leukemia with remission. After several years, the testicular recurrence is confirmed by testicular fine needle aspiration. Orchiectomy and biopsy of the contralateral testicle was performed.
Comments. Relapse in patients with acute lymphoblastic leukemia affects usually the bone marrow. Testicular involvement, along with the brain, are signs of poor prognosis. The testicle is affected in less than 1% of cases. Testicular relapses have been suggested to be due to the presence of a cell clone different from the one that produces relapse in the bone marrow and that would be immune to chemotherapy treatment.
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Case 128. Infiltration by Chronic Lymphatic Leukemia (CLL): Fungus Testis
Clinical case. A patient with CLL with no current treatment by his own decision. Four weeks earlier, he had a feverish peak associated with edema and scrotal swelling. He was diagnosed a right orchidoepididymitis and administered antibiotics. His evolution is poor, so a testicular abscess was suspected and scrotal spontaneous suppuration was observed. The ultrasound showed an increase of his right testicle volume, of heterogeneous echogenicity, a moderate decrease in vascularization that associated important inflammatory changes in the epididymis and the ipsilateral covers. As a first possibility, these findings were suggestive of right orchiepididymitis in evolution but without being able to rule out an underlying tumor pathology. Testicular microcalcifications were also observed. No collections suggestive of abscesses or hydrocele were identified.