Paediatric radiologyCase Type
Olga María Suárez Traba, Inés Solís Muñiz, Teresa María Cañas Maciá, María Isabel Rozas Gómez, Elena García Esparza, Gustavo Albi Rodríguez, Sara Inmaculada Sirvent Cerdá, Miguel Angel López PinoPatient
16 years, male
A 16-year-old patient who underwent right orchidopexy in 2017 due to cryptorchidism, was admitted at our Department of Radiology to perform a testicular ultrasound. A left testicular mass was observed. After carrying out an extension study, he was scheduled for an orchiectomy which was performed without complications.
- Testicular Ultrasound: The left testicle was slightly increased in size with respect to the contralateral one, with a large lesion occupying its middle and distal third. The lesion was very heterogeneous, with a multiseptated cystic appearance (Fig. 1) and some calcifications located in its upper margin (Fig. 2a, b). The lesion measured 31 x 32 mm (maximum axes) and no significant vascularisation in the colour Doppler study was observed (Fig. 3). The rest of the left testicular parenchyma had several hyperechogenic foci compatible with microlithiasis (Fig. 4).
- Left epididymis and scrotal covers did not present alterations.
- Isolated microlithiases were observed in the right testicle.
- Abdominal ultrasound and chest radiography did not identify any significant findings.
- Hormonal study was normal: alpha-fetoprotein 1.83 ng/ml (normal reference values 1-15) and B-HCG < 1.2 mIU/ml (normal reference values 0.01-5).
Testicular tumours represent 1-2% of solid neoplasms in childhood and are usually diagnosed at two peaks of age: at 2-4 years and towards 15 years. The approximate incidence in the general population is 0.5-2/100,000 [1, 2, 3, 4, 16].
Several risk factors have been described in the literature associated with the development of testicular tumours, the most frequent are: history of testicular maldescent, history of orchidopexy, testicular atrophy, previous germ cell tumour in the contralateral testicle, history of germ cell tumour in a 1st degree relative, infertility, Klinefelter syndrome, etc. [5, 6, 7]
Another risk factor related to the development of testicular tumours and widely discussed in the literature is the presence of microlithiasis [7, 8, 9, 10]. There are articles that show a very direct relationship in both adults and children [9, 10], while others refute this theory [8, 7].
In this case, our patient presented with bilateral isolated testicular microlithiasis and although he had a history of cryptorchidism, it was on the contralateral side.
Testicular tumours are divided into 6 groups according to the Pathological Classification of the World Health Organization 2016 . In this classification, two types of teratomas are differentiated, prepubertal type and postpubertal type, with better prognosis for the first one [11, 12].
Teratomas are usually benign in prepubertal patients, but they can be malignant when they appear in adults . Histologically, they present a combination of the 3 primitive embryological layers (ectoderm, endoderm and mesoderm) and its appearance is frequently heterogeneous. In ultrasound they present a variable appearance: simple cysts, multicystic lesions or solid-cystic lesions. Both diffuse and localised calcifications are frequent and their size can be variable, from small to voluminous lesions [4, 13, 14,16]. In the case we present, the teratoma was multiseptated with some localised calcifications in its upper pole.
Orchiectomy is the treatment of choice, although in recent years several articles have published a conservative surgical approach with tumorectomy in those patients included in the benign testicular tumour criteria (like small size, viable normal testicular tissue in US and negative tumour markers) [3, 15].
Written informed patient consent for publication has been obtained.
 Xiaokun Lin, Dazhou Wu, Na Zheng, Qiongzhang Xia, Yijiang Han. Lin et al (2017) Gonadal germ cell tumors in children. A retrospective review of a 10-year single-center experience. Medicine 96:26. (PMID: 28658171)
 Jonathan H. Ross, MD, Robert Kay, MD (2004) Prepubertal Testis Tumors. Reviews in Urology 6(1): 11–18 (PMID: 16985566)
 Romo Muñoz MI, Núñez Cerezo V, Dore Reyes M, Vilanova Sánchez A, González-Peramato P, López Pereira P, Martínez Urrutia MJ (2018) Testicular tumours in children: Indications for testis-sparing surgery? An Pediatr 88(5):253-258 (PMID: 28729185)
 F.J. Caballero Mora, M.T. Muñoz Calvo, M. García Ros, J. Rodríguez de Alarcón, M.L. Fernández Pérez, F. Casco y J. Argente (2013) Tumores testiculares y paratesticulares en la infancia y adolescencia. An Pediatr 78(1):6-13 (PMID: 22727932)
 Richenberg J, Belfield J, Ramchandani P, Rocher L, Freeman S, Tsili AC, Cuthbert F, Studniarek M, Bertolotto M, Turgut AT, Dogra V, Derchi LE (2015) Testicular microlithiasis imaging and follow-up: guidelines of the ESUR scrotal imaging subcommittee. Eur Radiol 25:323–330 (PMID: 25316054)
 E. Gálvez González, M. Villanueva Delgado, B. Prieto Hernández, M. Gonzalo Dominguez, M. Vacas Rodríguez (2012) Tumores testiculares. EPOS. European Society Radiology. Doi: 10.1594/seram2012/S-0762
 Richenberg J, Brejt N (2012) Testicular microlithiasis: is there a need for surveillance in the absence of other risk factors? Eur Radiol 22(11):2540-6 (PMID: 22710430)
 Bhargavi Kola (2017) Pediatric Testicular Microlithiasis: To Refer or Not to Refer? Global Pediatric Health Vol 4: 1-3. (PMID: 29051915)
 Howard T. Heller, Matthew C. Oliff, Peter M. Doubilet, Michael P. O’Leary, Carol B. Benson (2014) Testicular Microlithiasis: Prevalence and Association with Primary Testicular Neoplasm. JOURNAL OF CLINICAL ULTRASOUND Vol. 42, NOº 7 (PMID: 24585495)
 Andrew T. Trout, Jeanne Chow, Erin R. McNamara, Kassa Darge, Raul Ramirez Grueso, Marthe Munden, Sarah M. Rothan, Oscar M. Navarro, Marta Tijerín Bueno, Kevin E. Bove, Kudakwashe R. Chikwava, Amer Heider, M. John Hicks, Gino R. Somers, Bin Zhang, Jonathan R. Dillman (2017) Association between Testicular Microlithiasis and Testicular Neoplasia: Large Multicenter Study in a Pediatric Population. Radiology: Volume 000: Number 0 (PMID: 28715257)
 Holger Moch, Antonio L. Cubilla, Peter A. Humphrey, Victor E. Reuter, Thomas M. Ulbright (2016) The 2016 WHO Classification of Tumours of the Urinary System and Male Genital organs—Part A: Renal, Penile, and Testicular Tumours. Eur Urol 70(1): 93-105. (PMID: 26935559)
 Semjén David, Farkas András, Kalman Endre, Kaszas Balint, Kovács Árpad, Pusztai Csaba, Szuhai Karoly, Tornóczky Tamás (2017) More Cases of Benign Testicular Teratomas are Detected in Adults than in Children. A Clinicopathological Study of 543 Testicular Germ Cell Tumor Cases. Pathol. Oncol. Res 23(3): 513-517 (PMID: 27796764)
 Matias Epifanio, Marilisa Baldissera, Fernando G. Esteban, and Matteo Baldisserotto (2014) Mature Testicular Teratoma in Children: Multifaceted Tumors on Ultrasound. Urology 83(1):195-7 (PMID: 24080220)
 Edward K. Sung, Bindu N. Setty, Ilse Castro-Aragon (2012) Sonography of the Pediatric Scrotum: Emphasis on the Ts- Torsion, Trauma, and Tumors. AJR Am J Roentgenol 198(5): 996-1003. (PMID: 22528888)
 15: Anna Bujons, Jorge Caffaratti Sfulcini, Merce Pascual, Oriol Angerri Feu, José María Garat and Humberto Villavicencio (2011) Prepubertal testicular tumours and efficacy of testicular preserving surgery. BJU Int 107(11): 1812-6. (PMID: 21040368)
 Celestino Aso, Goya Enríquez, Marta Fité, Nuria Torán, Carmen Piró, Joaquim Piqueras, Javier Lucaya (2005) Gray-scale and color Doppler sonography of scrotal disorders in children: an update.. Radiographics 25(5):1197-214 (PMID: 16160106)
 Munden MM, Trautwein LM (2000) Scrotal pathology in pediatrics with sonographic imaging. Curr Probl Diagn Radiol 29(6):185-205. (PMID: 11104171)