| ORIGINAL REPORTS |
Howard L. Adler, M.D., Scott Department of Urology
John L. Haddad, M.D., Department of Radiology
Thomas M. Wheeler, M.D., Scott Department of Urology,Department of Pathology
Edward D. Kim, M.D., Scott Department of Urology
The Methodist Hospital
Baylor College of Medicine Houston, Texas
INTRODUCTION
Adenomatoid tumors are benign neoplasms which commonlyoccur in the paratesticular tissues. Testicular adenomatoid tumors havebeen reported previously and almost always arise from the tunica albuginea.To date, only three cases of primary intratesticular adenomatoid tumorshave been described.1-3 We now describe a case of a young manwho was found to have an intratesticular adenomatoid tumor in continuitywith the rete testis.
CASE HISTORY
A 36-year-old male of Hispanic and African-American descentpresented with a three week history of a non-tender right scrotal/testicularlesion. The patient denied any history of prior trauma, epididymitis, cryptorchidism,groin surgery, or unprotected intercourse. On physical examination, thepatient was found to have minimal induration at the superior aspect ofthe right epididymis. The right and left testes were both normal to palpation.Scrotal ultrasound revealed a normal right testicleand normal epididymides. A 6 mm heterogeneous mass was incidentally discoveredin the lower pole of the left testicle (Figure1). Magnetic resonance scan (MRI) demonstrated the lesionto be hypointense to the normal testicular parenchyma on T2-weighted images(Figure 2A).This lesion enhanced greater than the surroundingparenchyma on T1-weighted images obtained after intravenous administrationof gadolinium-DTPA (Figure2B). Serum beta-human chorionic gonadotrophin and alpha-fetoproteinlevels were both undetectable. A left radical orchiectomywas performed. Pathology revealed an intratesticular adenomatoid tumorin continuity with the rete testis (Figures3A and 3B). There was no association of the tumor with the tunica albugineaidentified.
DISCUSSION
Adenomatoid tumors are the most common tumor of the paratesticulartissues and usually occur between the third and fourth decades of life.3Adenomatoid tumors involving the testicle usually arise from the tunicaalbuginea and invade the testicular parenchyma. Tammela et al describe8 patients who were found to have adenomatoid tumors of the tunica albuginea.In each case, the tumor was located superficially in the tunica albugineaat the lower pole of the testis. Only one patient had an orchiectomy, whilethe other patients were treated with local excision. These patients werefound to have tumors which were isoechoic, hypoechoic, or heteroechoicby ultrasonography. Furthermore, the lesions were noted to be clearly outsidethe testicular parenchyma and unlikely to be malignant.4
In contrast, three cases of primary intratesticular adenomatoidtumors have been previously described.1-3 In each case, thebenign nature of the testicular mass could not be determined preoperatively.Two of the three previous cases were treated with inguinal orchiectomy.1,2Moreover, the patient described by Somers was found to have an intratesticularlesion by ultrasonography.2 The patient described by Samad etal refused orchiectomy unless a malignancy could be identified; consequently,he had primary excision of the lesion with intraoperative frozen sections.3
Our patient had a heterogeneous mass of the left testicleidentified by ultrasonography. Feuer et al described the ultrasonographiccharacteristics of three men with testicular adenomatoid tumors. Two patientshad isoechoic lesions while the third patient had a normal testicular ultrasound.The authors, however, did not state if these lesions were contiguous withthe tunica albuginea.5 These findings are in contrast to thoseof the suspicious ultrasonographic findings in our patient and in the patientdescribed by Somers.2
The MRI appearance of this lesion has not been previouslyreported. MRI scan only served to heighten our suspicion that this wasa malignant lesion, as the presence of a discrete solid enhancing lesionwas confirmed. Our case is also distinguished from the other reported casesin that this tumor was identified on diagnostic ultrasonography for symptomaticcomplaints in the opposite testicle. Scrotal ultrasonography and MRI failedto identify any pathology within the right testicle.
In conclusion, testicular adenomatoid tumors are rarebenign lesions with clinical presentations similar to that of malignanttesticular neoplasms. The radiographic findings of testicular adenomatoidtumors are variable. Patients who present with vague scrotal and/or testicularcomplaints may benefit from scrotal imaging studies. Furthermore, any suspiciouslesions identified by sonography should be treated with inguinal orchiectomygiven the extremely low incidence of benign testicular neoplasms. Patientswith isoechoic or sonographically normal lesions may benefit from inguinalexploration with excisional biopsy and frozen sections.
REFERENCES:
1. Horstman, W.G., Sands, J.P. and Hooper DG: Adenomatoidtumor of the testicle. Urology 40: 359, 1992.
2. Somers, W.J.: The sonographic appearance of an intratesticularadenomatoid tumor. J Clin Ultrasound 20: 479, 1992.
3. Samad, A.A., Pereiro, B., Badiola, A., Gallego, C.and Zungri, E.: Adenomatoid tumor of intratesticular localization. EurUrol 30: 127, 1996.
4. Tammela, T.L.J., Karttunen, T.J., Makarainen, H.P.,Hellstrom, P.A., Mattila, S.I. and Konturri, M.J.: Intrascrotal adenomatoidtumors. J Urol 146: 61, 1991.
5. Feuer, A., Dewire, D.M. and Foley, W.D.: Ultrasonographiccharacteristics of testicular adenomatoid tumors. J Urol 155: 174, 1996.
