CASE 18004 Published on 06.02.2023

Bilateral Testicular Relapse of B-Acute Lymphoblastic Leukaemia


Uroradiology & genital male imaging

Case Type

Clinical Cases


Yuxuan Jiang1, Scott Caterine2, Stefanie Y. Lee2

1. Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada

2. Department of Radiology, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada


31 years, male

Area of Interest Genital / Reproductive system male ; Imaging Technique Ultrasound-Colour Doppler
Clinical History

31-year-old male presenting with scrotal swelling and 5/10 left testicular and inguinal pain, two weeks after contracting COVID-19. Past medical history includes stem cell transplantation for haematologic malignancy over one year ago. Examination revealed a swollen, tender left testis, with dusky and erythematous left scrotal skin.

Imaging Findings

Testicular ultrasound revealed diffuse asymmetric enlargement of the left testis, with near complete replacement of the parenchyma by a solid hypoechoic mass. No flow was detected within the left testis on colour and power Doppler.

Additional findings of the right testis showed a well-circumscribed, mildly lobulated solid hypoechoic lesion measuring 1.9 cm, with internal vascularity on Doppler examination.



This case of pathologically confirmed testicular relapse of acute lymphoblastic leukaemia (ALL) was complicated by subacute testicular ischemia in a patient with a history of haploidentical stem cell transplant. ALL is rare in the adult population, with an average incidence of 1.28 per million (1). Testicular relapse is as low as 2% due to intensive methotrexate dosing, but is responsible for 20% of failed ALL remissions (2). Bilateral testicular involvement occurs in 8 to 15% of cases (3).

Clinical Perspective

ALL testicular relapse may present as painless testicular swelling or a palpable nodule. Tumour infiltration may result in ischemia and pain. In our case, diagnosis was complicated by scrotal pain during COVID-19 infection 10 days prior, during which the patient was first treated for viral orchitis without symptom resolution. Ultrasound is the first-line modality in assessing acute scrotal pain, and can identify masses, ischemia, and inflammation/infection. If the appearance is suspicious for testicular torsion, findings should be relayed immediately to the referring physician given the need for emergent surgery to preserve testicular viability.

Imaging Perspective

Ultrasonography of testicular ALL typically shows diffuse hypoechoic enlargement or focal hypoechoic masses corresponding to lymphocytic infiltration, with increased Doppler flow (3). Normal architecture of the testicular vessels within the areas of lymphocytic infiltration may help distinguish ALL from other primary testicular malignancies (4). In our case, the infiltration of the left testis was complicated by ischemia and absent vascular flow on Doppler interrogation. The differential diagnosis would also include infectious orchitis; however, absence of increased vascularity and the presence of a focal mass in the right testis make this less likely.


ALL testicular relapse is usually treated with a combination of chemotherapy, testicular or total body radiation with hematopoietic cell transplantation, and/or orchiectomy. Prognostic information for isolated testicular ALL relapse in adults is lacking, but the 4-year event-free survival in the paediatric population is estimated at 53 – 84% (6).

Our patient underwent bilateral orchiectomy without complications. Pathologic examination confirmed bilateral testicular infiltration by B Acute Lymphoblastic Leukaemia.

Take-home Message

While testicular infiltration of ALL is usually vascular, the absence of flow on Doppler raises concern for ischemic complication. 

All patient data have been completely anonymised throughout the entire manuscript and related files.

Differential Diagnosis List
Bilateral testicular infiltration by B Acute Lymphoblastic Leukaemia
Primary testicular malignancy
Testicular torsion with torsion-detorsion syndrome
Infectious orchitis
Final Diagnosis
Bilateral testicular infiltration by B Acute Lymphoblastic Leukaemia
Case information
DOI: 10.35100/eurorad/case.18004
ISSN: 1563-4086