Figure 1
Figure 1
RX of the Abdomen
The importance of being ‘Visited’
SectionUroradiology & genital male imaging
Case TypeClinical Cases
AuthorsRinaldi D, Breveglieri B, Fiocchi F, Torricelli P
Connected authors
37 years, male
Clinical History
A 37-year-old male patient was admitted to the emergency department due to general uneasiness, temperature, vomiting and dysentery. He was not collaborative, depressed, thin and suffered from increased perspiration for some months. Anamnestic data was orchidectomy post cryptorchism nine years before. At the moment of admission he was not deeply visited.
Imaging Findings
First a radiography of the abdomen showed in the left pubic region a mass with some air bubbles (Fig. 1). Therefore the patient was better analysed and a huge pubic mass was discovered. The lesion was ulcerated and maleodorant, suspicious for Fournier’s gangrene. Neoplastic markers were normal (AFP and HCG).
To evaluate the extent and anatomic relations of the lesion a CT was performed that confirmed the presence of a huge disproliferative mass in the pubic-inguinal area of 10x27x22 cm that involved scrotum, penis, thigh, muscles and skin. The lesion presented dishomogeneous enhancement and diffuse emphysema, expression of a concomitant abscessual process (Fig. 2).
Many lymphadenopathies were presents in external iliac and right inguinal lymph nodes but no metastases were shown. PET-CT (performed after resection of necrotic skin) highlighted FDG uptake of the lymphadenopathies and of the left inguinal region (Fig. 3). Biopsy of the mass showed malignant germinal cell’s neoplasm, seminal type.
To evaluate the extent and anatomic relations of the lesion a CT was performed that confirmed the presence of a huge disproliferative mass in the pubic-inguinal area of 10x27x22 cm that involved scrotum, penis, thigh, muscles and skin. The lesion presented dishomogeneous enhancement and diffuse emphysema, expression of a concomitant abscessual process (Fig. 2).
Many lymphadenopathies were presents in external iliac and right inguinal lymph nodes but no metastases were shown. PET-CT (performed after resection of necrotic skin) highlighted FDG uptake of the lymphadenopathies and of the left inguinal region (Fig. 3). Biopsy of the mass showed malignant germinal cell’s neoplasm, seminal type.
Discussion
Seminoma is a germinal cell neoplasm that represents 40% of testis tumours and occurs in puberty and in adult age (30-40 years old); generally the localisation is “rete testis” and three types are distinguished: typical, spermatocitic and anaplastic.
Neoplastic process spreads by proximity, by lymphatic system and circulation system; often symptoms are increase of volume and consistency of testis (painless nodule).
Markers AFP e HCG usually are not elevated. US is usually the first diagnostic tool in the scrotal masses, establishing whether they are intra or extra-testicular.
CT is usually performed to analyse the extent of the mass and the presence of local or distant metastases. In CT images, if testicles are included in scansion, tumour appears as intratesticular mass, homogeneously hypo-dense and sometimes lobulated; it can contain central areas of necrosis and it is hypovascularised; para-aortic lymph nodes with diameter on short axis major than 10 mm are suspicious for neoplastic involvement.
Fournier’s gangrene, also named Fournier’s syndrome, is a bacterial infection rare in antibiotic age that affects perineum and genitalia, often caused by anaerobic microrganisms (first of all streptococcus emoliticus) and characterised by the gravity of the patient’s condition.
Diabetes, immunodeficiency, alcoholism, neoplastic conditions and liver or kidney pathologies are comorbidities associated with the development of this infection. The diagnosis of FG is clinically based on history and physical examination, and supported by radiological imaging in select cases. In this case CT is permitted to evaluate the disease and its extension, to confirm the connection between neoplasm and infection and to address the correct management of the patients in order to formulate systemic chemotherapy, antibiotic therapy and local surgery. PET is permitted to evaluate metabolic activity in inguinal lymph nodes and in inguinal soft tissues before and after surgical toilette of the region.
The patient has undergone a surgical toilette of infected tissues and 4 cycles of chemotherapy with Protocol PEB and (Cisplatin – Etoposide – Bleomycin) and PET-CT with iodine contrast media at follow-up has shown complete regression of pathology: fibrotic tissue with no metabolic activity (Fig. 4).
Neoplastic process spreads by proximity, by lymphatic system and circulation system; often symptoms are increase of volume and consistency of testis (painless nodule).
Markers AFP e HCG usually are not elevated. US is usually the first diagnostic tool in the scrotal masses, establishing whether they are intra or extra-testicular.
CT is usually performed to analyse the extent of the mass and the presence of local or distant metastases. In CT images, if testicles are included in scansion, tumour appears as intratesticular mass, homogeneously hypo-dense and sometimes lobulated; it can contain central areas of necrosis and it is hypovascularised; para-aortic lymph nodes with diameter on short axis major than 10 mm are suspicious for neoplastic involvement.
Fournier’s gangrene, also named Fournier’s syndrome, is a bacterial infection rare in antibiotic age that affects perineum and genitalia, often caused by anaerobic microrganisms (first of all streptococcus emoliticus) and characterised by the gravity of the patient’s condition.
Diabetes, immunodeficiency, alcoholism, neoplastic conditions and liver or kidney pathologies are comorbidities associated with the development of this infection. The diagnosis of FG is clinically based on history and physical examination, and supported by radiological imaging in select cases. In this case CT is permitted to evaluate the disease and its extension, to confirm the connection between neoplasm and infection and to address the correct management of the patients in order to formulate systemic chemotherapy, antibiotic therapy and local surgery. PET is permitted to evaluate metabolic activity in inguinal lymph nodes and in inguinal soft tissues before and after surgical toilette of the region.
The patient has undergone a surgical toilette of infected tissues and 4 cycles of chemotherapy with Protocol PEB and (Cisplatin – Etoposide – Bleomycin) and PET-CT with iodine contrast media at follow-up has shown complete regression of pathology: fibrotic tissue with no metabolic activity (Fig. 4).
Differential Diagnosis List
Gangrena di Fournier incurred on testicle’s seminoma
Neoplastic disease
Bacterial Infection
Final Diagnosis
Gangrena di Fournier incurred on testicle’s seminoma
References
[1] Eke N (2008) Fournier\'s gangrene, still an enigma. J Postgrad Med 54:83-4 (PMID: 18480520)
[2] Unalp HR, Kamer E, Derici H, Atahan K, Balci U, Demirdoven C, Nazli O, Onal MA (2008) Fournier\'s gangrene: Evaluation of 68 patients and analysis of prognostic variables. Postgrad Med 54:102-5 (PMID: 18480525)
[3] Richie JP, Birholz J, Garnick MB (1982) Ultrasonography as a diagnostic adjunct for the evaluation of masses in the scrotum. Surg Gynecol Obstet 154: 695 (PMID: 7071705)
[4] Corcoran AT, Smaldone MC, Gibbons EP, Walsh TJ, Davies BJ (2008) Validation of the Fournier\'s gangrene severity index in a large contemporary series. J Urol 180:944-8 (PMID: 18635215)
Case information
| URL: | https://www.eurorad.org/case/9020 |
| DOI: | 10.1594/EURORAD/CASE.9020 |
| ISSN: | 1563-4086 |
Figure 2
Figure 2
CT
Figure 3
Figure 3
PET-CT after surgical toilette
Figure 4
Figure 4
CT-PET after 4 cycles of chemotherapy
Figure 1
RX of the Abdomen
Figure 2
CT
Figure 3
PET-CT after surgical toilette
Figure 4
CT-PET after 4 cycles of chemotherapy