CASE 18004 Published on 06.02.2023

Bilateral Testicular Relapse of B-Acute Lymphoblastic Leukaemia

Section

Uroradiology & genital male imaging

Case Type

Clinical Cases

Authors

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

Patient

31 years, male

Categories

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

No Procedure ; No Special Focus ;

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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.

Discussion

Background

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.

Outcome

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

References

[1] Hoelzer D, Bassan R, Dombret H, Fielding A, Ribera JM, Buske C. Acute lymphoblastic leukaemia in adult patients: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up †. Ann Oncol. 2016 Sep 1;27:v69–82. (PMID: 27056999)

[2] Chang JHC, Poppe MM, Hua CH, Marcus KJ, Esiashvili N. Acute lymphoblastic leukemia. Pediatr Blood Cancer. 2021 May;68 Suppl 2:e28371. (PMID: 33818880)

[3] Moreno CC, Small WC, Camacho JC, Master V, Kokabi N, Lewis M, et al. Testicular Tumors: What Radiologists Need to Know—Differential Diagnosis, Staging, and Management. RadioGraphics [Internet]. 2015 Mar 12 [cited 2022 Jul 17]; Available from: https://pubs.rsna.org/doi/10.1148/rg.352140097. (PMID: 25763725)

[4] Bertolotto M, Derchi LE, Secil M, Dogra V, Sidhu PS, Clements R, et al. Grayscale and Color Doppler Features of Testicular Lymphoma. J Ultrasound Med. 2015;34(6):1139–45. (PMID: 26014335)

[5] Nguyen HTK, Terao MA, Green DM, Pui CH, Inaba H. Testicular involvement of acute lymphoblastic leukemia in children and adolescents: Diagnosis, biology, and management. Cancer. 2021;127(17):3067–81. (PMID: 34031876)

[6] Wofford MM, Smith SD, Shuster JJ, Johnson W, Buchanan GR, Wharam MD, et al. Treatment of occult or late overt testicular relapse in children with acute lymphoblastic leukemia: a Pediatric Oncology Group study. J Clin Oncol Off J Am Soc Clin Oncol. 1992 Apr;10(4):624–30. (PMID: 1548525)

Case information

URL:	https://www.eurorad.org/case/18004
DOI:	10.35100/eurorad/case.18004
ISSN:	1563-4086

License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

Sagittal greyscale ultrasound image of the right testis demonstrates a well-circumscribed, solid hypoechoic lesion measuring 1.9 cm with mildly lobulated margins (arrows)

Transverse greyscale ultrasound image of the right testis demonstrates a well-circumscribed, solid hypoechoic lesion measuring 1.9 cm with mildly lobulated margins (arrows)

Sagittal colour Doppler image of the right testis demonstrates vascular flow within the solid lesion (arrows)

Transverse power Doppler image of the right testis demonstrates vascular flow within the solid lesion (arrows)

Figure 2

Sagittal greyscale ultrasound image of the left testis demonstrates diffuse asymmetric enlargement and near complete replacement of the parenchyma by a solid hypoechoic mass containing scattered punctate echogenic foci (arrows)

Transverse greyscale ultrasound image of the left testis demonstrates diffuse asymmetric enlargement and near complete replacement of the parenchyma by a solid hypoechoic mass containing scattered punctate echogenic foci (arrows)