Goubaa Mohamed MD Djerba Tunisia

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This is a 40-year-old male with a one-month history of an enlarging mass in the right hemiscrotum. There was no history of hernia repair, epididymitis, urinary tract infections, venereal disease, or trauma. There was no associated dysuria or hematuria. Physical examination was unremarkable with the exception of the firm scrotal mass. C'est un homme âgé de 40 ans avec comme histoire une masse grandissante dans l'hémi-scrotum droit. Il n'y avait aucun antécédent de chirurgie réparatrice d'hernie, d'épididymite, d' infection urinaire, de maladie vénérienne, ou de trauma. Il n'y avait aucune dysurie ou hématurie associées. L'examen physique était normal a part la masse scrotale ferme.



ultrasonography seminoma

échographie echographie séminome seminome

echography testicle tumor cancer

doppler testicule cancer tumeur

ultrasound teticular seminoma


scanner seminoma cancer testicle

metastasis liver seminoma testicle

lymph node metastasis métastase

lung ultrasonography

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The right hemiscrotum contains a markedly enlarged right testicle measuring approximately 5 x 5 cm. There is no identifiable normal testicular tissue. The left testicle is normal Sonographically, the differentiation of normal tissue from tumor is very difficult in this case, but intratesticular masses are almost always malignant (whereas extratesticular masses are usually benign). CT scan show the tumor (scan 7) and only pulmonary metastasis (scan 10). Ultrasound shows liver metastasis (scan 8) and also pulmonary metastasis (scan 11) and abdominal lymph node metastasis (scan 9). L' hémi-scrotum droit contient un testicule droit nettement agrandi mesurant approximativement 5 x 5 cm. Il n'y a pas de tissu testiculaire normal identifiable. Le testicule gauche est normal A l'échographie, la différentiation du tissu normal de la tumeur est très difficile dans ce cas-ci, mais les masses intra-testiculaires sont presque toujours malignes (tandis que les masses testiculaires extra-testiculaires sont habituellement bénignes). Le balayage au scanner montre la tumeur (cliché 7) et les métastases pulmonaire (cliché 10). Les L'échographie montre le métastases de foie (cliché 8) et aussi les métastases pulmonaires (cliché 11) et des métastases lymphatique ganglionnaires abdominales (cliché 9).



Testicular cancer (seminoma) Cancer testiculaire (séminome)


Testicular Neoplasms

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In the diagnosis and staging of testicular tumor, imaging studies are of primary importance. Although most tumors are diagnosed based on physical examination findings, scrotal ultrasound is typically performed to ensure the correct diagnosis or to establish a diagnosis in a patient in whom the testicular examination cannot differentiate the scrotal structures.
Testicular tumors occur most frequently in the 20 to 40 year age group and make up 1 to 2 % of all cancers in males and 1.5 pet cent of all childhood malignancies. Their incidence is increased 5 to 100 times in undescended testicles.
15 % of testicular tumors present with a hydrocoele whilst others present with a testicular mass or distant metastases. 10 % of patients present with acute pain due to intratesticular hemorrhage. Metastases may be present at présentation in 4 to 14 % of patients to lung, liver, bones, brain and lymph nodes.

Classification of Testicular Neoplasms
Germ cell tumors
-- Seminoma
--Embryonal cell
--Yolk sac
--Mixed germ cell
Stromal tumors
--Leydig cell tumor
--Sertoli cell tumor
Epidermoid cyst

Ultrasonography :
An intratesticular mass is malignant until proven otherwise.
Sonography is highly sensitive in detecting testicular tumors : 95% to 100%. Determination by the sonographer of whether the mass is intratesticular or extratesticular in location is important. Scrotal sonography approaches 100 % accuracy in distinguishing an intratesticular mass from an extratesticular mass. In addition, sonography is extremely accurate in determination of the exact location of a scrotal mass, but it is less accurate in distinguishing whether an intratesticular mass is malignant or benign.
Over 90 % of testicular neoplasms are completely or predominantly hypoechoic. Infarction and inflammation may also give rise to focal hypoechoic areas and thus a hypoechoic focus does not necessarily indicate malignancy.
High-frequency sonography is a very accurate means of demonstrating testicular parenchyma and a normal scan is almost 100 % accurate at excluding testicular malignancy. Color Doppler sonography show little vascularity in tumors less than 1.5 cm in size but tumors larger than 1.6cm consistently display hypervascularity and distortion of blood vessels.

Differential :
There are numerous lesions that can simulate testis tumors. These include :
* infarcts.
* focal orchitis.
* focal fibrosis.
* hematomas.
* abscesses.
* sarcoid.
* tuberculosis.
* adrenal rest tissue.
In many cases the patient's history is useful in suggesting the correct diagnosis.
One relatively common abnormality that is easy to mistake for a tumor is testicular atrophy and fibrosis. In most patients these conditions can produce hypoechoic regions in the testis that are arranged in a linear pattern, producing a striated appearance to the testis that does not simulate a tumor. However, if these areas become more confluent, they can be misdiagnosed as tumors. This mistake can usually be avoided by scanning in multiple planes and noting the wedge shape or the abnormality and the way it radiates from the mediastinum.

This tumor accounts for 50 % of primary testicular neoplasm and is the most common tumor in the undescended testis. The age group affected is between 30 and 40 years. The tumors may be multifocal. A quarter already show metastases at presentation usually to the lungs. Tumor activity can be monitored by beta-human chorionic gonadotrophin which is elevated in 10 to 15 % of patients. The serum alpha in is usually normal.
Ultrasound appearances : Seminomas present as a solid, hypoechoic mass that is homogeneous, although occasionally scattered echogenic areas may be identified. Seminomas are usually unilateral and may be very small in size : 2 to 3 mm. Seminomas may also almost completely replace normal testicular parenchyma.

Embryonal cell tumor
It is the second most common type of testicular neoplasm and accounts for 25% of primary testicular neoplasms. They usually affect patients in their second and third decades and children under the age of 2 years. These tumors are the most aggressive testicular neoplasms that predispose to visceral metastases.
The commonest ultrasound appearance is that of a hypoechoic mass with irregular borders, that may show echogenic foci because of areas of calcification and cystic areas because of hemorrhage and necrosis. These tumors are aggressive and may distort the normal contour of the testicle when invasion of the tunica albuginea occurs.

Teratomas account for 5% to 10% of scrotal tumors and are generally seen in men between 25 and 35 years of age. The tumor may be benign in children but may transform into malignancy.
Sonographic Findings : Teratomas may contain hair, bone, and teeth. Teratomas are usually well differentiated and, depending on which tissue components they contain, may be hyperechoic, hypoechoic, or complex and demonstrate shadowing

The incidence of this tumor is 1 to 3 % with a peak age incidence of 20 to 30 years. The prognosis is poor and is rapidly fatal.
Ultrasound appearances : Choriocarcinomas usually present as a small mass with mixed echogenicity from hemorrhage, necrosis, and calcifications.

Yolk sac tumor
This is a rare tumor which is considered equivalent to the endodermal sinus tumor of the ovary. Yolk cell tumor elements are said to be present in 38 % of other adult germ cell tumors except a seminoma. The tumor primarily affects children under 3 years of age. The tumors frequently metastasise to the lung. Specific ultrasound appearances have not been described.

Testicular lymphoma
Non-Hodgkin's, especially B-cell lymphoma, represents the most common secondary neoplasm of the testis and the most common testicular malignancy in men over the age of 60 years. Sonographic Findings :Testicular lymphoma may appear hypoechoic and enlarged with anechoic masses. Lymphoma usually presents as a diffuse mass but occasionally may be focal.. The tumor may extend into the epididymis and spermatic cord but invasion of the tunica albuginea is usually rare.
Testicular leukemia
Sonography reveals diffuse or focal nodular decreased echogenicity with preservation of the ovoid testicular shape. Doppler ultrasound shows a strikingly increased vascular flow unrelated to the size or extent of the tumor, unlike that with primary testicular tumors.

Metastases to the testis
In adults the common primary sites that metastasise to the testis include the prostate, lungs, kidneys, gastrointestinal tract, bladder, thyroid and melanoma. In children neuroblastoma and Wilms' tumor is often implicated.
Sonographic Findings : metastases are often hypoechoic but echogenic masses may occur. The sonographic findings may be indistinguishable from lymphomas or primary testicular tumors.

Sertoli cell tumor
These testicular tumors, which arise from the Sertoli cells of the seminiferous tubules, are associated with hormonal abnormalities such as gynaecomastia and precocious puberty. Over 90 % of these tumors are benign and usually arise in the first year of life.
sonographic appearances : These testicular tumors are those of a smooth rounded area, 5 to 10 mm in size, with curvilinear calcification. Calcification within the testis without an associated soft tissue mass is strongly suggestive of this tumor. Doppler ultrasound may display increased blood flow within or adjacent to the lesion.

Leydig's Cell Tumors Leydig's
cell tumors are also called interstitial cell tumors and arise from the interstitial cells that form the fibrovascular stroma of the testis. These tumors account for 1% to 3% of testicular neoplasms. They are usually considered benign, but 10% of these tumors are malignant. As with Sertoli cell tumors they may be hormone secreting, which may be feminizing or result in precocious puberty.
The ultrasonic appearances are those of a hypoechoic mass. They may contain focal areas of hemorrhage and necrosis within the tumor, creating cystic areas identified in 25% of Leydig's cell tumors.

Reference :
* 1: Maizlin ZV, Belenky A, Baniel J, Gottlieb P, Sandbank J, Strauss S. Epidermoid cyst and teratoma of the testis: sonographic and histologic similarities. J Ultrasound Med. 2005 Oct;24(10):1403-9; quiz 1410-1.
* 2 : Arjhansiri K, Vises N, Kitsukjit W. Sonographic evaluation of the intrascrotal disease. J Med Assoc Thai. 2004 Sep;87 Suppl 2:S161-7.
* 3 : Kuroda I, Ueno M, Mitsuhashi T, Nakagawa K, Yanaihara H, Tsukamoto T, Deguchi N. Testicular seminoma after the complete remission of extragonadal yolk sac tumor : a case report. BMC Urol. 2004 Nov 16;4:13.
* 4 : Maizlin ZV, Belenky A, Kunichezky M, Sandbank J, Strauss S. Leydig cell tumors of the testis: gray scale and color Doppler sonographic appearance. J Ultrasound Med. 2004 Jul;23(7):959-64.
* 5 : Hodzic J, Golka K, Schulze H. Primary testicular carcinoid. Med Sci Monit. 2004 Aug;10(8):CS46-8. Epub 2004 Jul 23.
* 6 : Carmignani L, Gadda F, Gazzano G, Nerva F, Mancini M, Ferruti M, Bulfamante G, Bosari S, Coggi G, Rocco F, Colpi GM. High incidence of benign testicular neoplasms diagnosed by ultrasound. J Urol. 2003 Nov;170(5):1783-6.
* 7 : de la Torre Holguera P, Villavicencio Mavrich H. [Testicular tumor. Ultrasonography study] Arch Esp Urol. 2000 Jul-Aug;53(6):423-31. Spanish.
* 8 : Gallardo Agromayor E, Pena Gomez E, Lopez Rasines G, Ortega Garcia E, Calabia de Diego A, Portillo Martin JA, Martin Garcia B. [Testicular tumors. Echographic findings] Arch Esp Urol. 1996 Jul-Aug;49(6):622-6. Spanish.
* 9 : Horstman WG, Melson GL, Middleton WD, Andriole GL. Testicular tumors: findings with color Doppler US. Radiology. 1992 Dec;185(3):733-7.