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Case Report |
1
Department of Radiology, Montefiore Medical Center, 111 E. 210th St., Bronx,
NY 10467.
2
Weiler Hospital, Albert Einstein College of Medicine, 1825 Eastchester Rd.,
Bronx, NY 10461.
Received July 26, 1999;
accepted after revision October 18, 1999.
Address correspondence to M. Koenigsberg.
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-fetoprotein, and ß-human chorionic
gonadotropin, were normal. Bilateral testicular sonography was performed before surgical intervention. The right testis had a normal homogeneous echotexture. The left testis had a mildly heterogeneous mass with diffusely interspersed areas of increased and decreased echogenicity occupying most of the parenchyma. Several calcifications, ranging in size from 1 to 3 mm in length, were visible inside the mass (Fig. 1A). Color Doppler sonography (wall filter, 1; scale range, +2.3 to -2.3 cm/sec) revealed intense diffuse flow throughout the mass, with normal flow in the surrounding normal parenchyma (Fig. 1B). Spectral Doppler traces (sample volume, 2 mm) were obtained in five random sites in the mass and five measurements were obtained at each site. Peak systolic velocities in the five sites ranged from 14 to 85 cm/sec (mean, 43 cm/sec), end diastolic velocities ranged from 5 to 17 cm/sec (mean, 9 cm/sec), and resistive indexes ranged from 0.33 to 0.94.
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The patient underwent radical left inguinal orchiectomy. Pathologic examination of the left testis revealed virtual replacement of the parenchyma with a pink and tan fleshy mass (Fig. 1C). Macroscopic evaluation revealed a proliferation of benign small slitlike vessels, sometimes in a fibrotic stroma, associated with thick-walled large arteries and veins. The histology findings were consistent with an arteriovenous-type hemangioma (Fig. 1D). Only rare seminiferous tubules and scattered stromal calcifications were visible. Immunohistochemical stains for CD34, Ulex europacus I lectin, and factor VIII confirmed the vascular nature of the tumor (Fig. 1E).
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Three of the five cases of testicular hemangioma reported in the literature include sonographic characterization of the lesions but lack Doppler imaging evaluation and two include Doppler imaging evaluation. Lozano et al. [2] described a 24-year-old man with a testicular hemangioma that appeared as a 2.5-cm well-circumscribed hyperechoic mass with a less hyperechoic central area on sonography. The rest of the testis appeared hypoechoic. Doppler data were not reported, and pathologic findings confirmed a cavernous hemangioma. Kratzik et al. [3] reported two patients with presumed testicular hemangiomas. Both patients, an 80-year-old man and another man with von Hippel-Lindau disease, had hypoechoic lesions. However, pathologic confirmation was not available. Frank et al. [4] described a 77-year-old man with a large cavernous hemangioma of the testis that appeared heterogeneous on sonography with hypoechoic areas and regions of calcific shadowing. Doppler data were not reported. Stille et al. [5] reported a 13-year-old boy with a testicular capillary hemangioma. Scrotal sonography confirmed a focal well-defined hypoechogenic mass in the right testis with "markedly increased blood flow and vascularity" on Doppler imaging. However, the velocity of flow was not reported. Finally, Essig et al. [6] described a 26-year-old man with a capillary hemangioma of the testis that appeared homogeneous and hypoechoic on sonography. No Doppler data were reported. On subsequent MR imaging, the lesion appeared isointense and hypointense on T1- and T2-weighted images, respectively, compared with normal testicular tissue. However, the lesion had higher signal intensity than muscle and exhibited "intense heterogeneous enhancement" on contrast-enhanced T1-weighted images.
Given the small number of cases in the literature, it is difficult to draw conclusions regarding the characteristic appearance of testicular hemangiomas. Generally, neoplasms larger than 1.5 cm are hypervascular [1]. In our patient, we noted three sonographic features of hemangioma. First, our patient's 2- to 3-cm lesion had intense, nearly diffuse, flow on color Doppler sonography. Moreover, the Doppler features of our patient's lesion correlated with an arteriovenous-type hemangioma on pathology, a lesion with enlarged tortuous feeding arteries, numerous smaller tortuous vessels, prominent dilated veins, and a rapid circulation with simultaneous visualization of arteries and veins on angiography. Color Doppler patterns may vary among different types of hemangiomas (capillary, cavernous, or venous) because some hemangiomas have slower flow or a lesser degree of vascular pooling [7]. Only Stille et al. [5] described color Doppler features of a cavernous hemangioma that exhibited similarly marked increased blood flow.
A second interesting feature of our patient's lesion was its Doppler spectral pattern. According to Middleton et al. [8], intratesticular arteries of normal testes have peak systolic velocities ranging from 4.0 to 19.1 cm/sec (mean, 9.7 cm/sec), end diastolic velocities ranging from 1.6 to 6.9 cm/sec (mean, 3.6 cm/sec), and resistive indexes ranging from 0.48 to 0.75 (mean, 0.61). Random measurements in our lesion revealed mean peak systolic velocities ranging from 14 to 85 cm/sec (mean, 43 cm/sec), end diastolic velocities ranging from 5 to 17 cm/sec (mean, 9.1 cm/sec), and resistive indexes ranging from 0.33 to 0.94. The lower resistive index foci in our patient's lesion are suggestive of vessels with higher diastolic velocity and lower resistance. The low-resistance pattern was probably caused by arteriovenous shunting. Arteriovenous fistula-type flow (relatively low velocity measurements) was not observed, probably because we randomly sampled the arterial side of the abnormal vessels rather than the venous side.
A third sonographic feature of our patient's lesion was the presence of calcifications of various sizes. Histologically, these calcifications represent stromal calcifications and not phleboliths. Frank et al. [4] also described regions of calcific shadowing in a cavernous hemangioma.
In conclusion, when a testicular mass has extensive hypervascularity and areas of low-resistance velocity on spectral Doppler imaging, we suggest that hemangioma be considered as a possible cause. Hemangiomas vary from hypoechoic to hyperechoic, or they may be heterogeneous [2,3,4,5,6], as in our patient. Calcifications of various sizes have been reported in our case and in that of one other [4]. Considering hemangioma on sonography is important because it may lead to organ-sparing surgery rather than radical orchiectomy in certain patients.
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