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DOI:10.2214/AJR.04.1895
AJR 2006; 186:483-490
© American Roentgen Ray Society

Pictorial Essay

Solid Extratesticular Masses in Children: Radiographic and Pathologic Correlation

Tammy Sung1, Wolfram F. J. Riedlinger2, David A. Diamond3 and Jeanne S. Chow4

1 Department of Radiology, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115.
2 Department of Pathology, Children's Hospital Boston, Boston, MA 02115.
3 Department of Urology, Children's Hospital Boston, Boston, MA 02115.
4 Department of Radiology, Children's Hospital Boston, Boston, MA 02115.

Received December 13, 2004; accepted after revision January 27, 2005.

 
Address correspondence to T. Sung (tsung{at}partners.org).


Abstract
Top
 Abstract
Introduction
 Painless Masses
 Painful Scrotal Masses
 Conclusion
 References
 
OBJECTIVE. The purpose of this pictorial essay is to review the sonographic and pathologic appearances of the most common solid and complex extratesticular masses in children.

CONCLUSION. Solid or complex extratesticular masses, especially those that are rapidly growing and are painless, raise concerns regarding malignant rhabdomyosarcoma. Mimickers of rhabdomyosarcoma include inflammatory processes such as pseudotumor, chronic epididymitis, or meconium periorchitis. Because sonography cannot distinguish benign from malignant, worrisome extratesticular masses should be biopsied or removed.

Keywords: genitourinary tract imaging • pediatric imaging • scrotal disease • sonography • testicular mass


Introduction
Top
 Abstract
 Introduction
Painless Masses
 Painful Scrotal Masses
 Conclusion
 References
 
Unlike solid extratesticular masses in adults, which are generally benign [1], 50% of painless extratesticular masses in children are malignant [2]. The most common neoplasm is paratesticular rhabdomyosarcoma.

Evaluation of scrotal disease in children begins with history and physical examination. Sonography, the imaging technique of choice [3], characterizes scrotal lesions as intratesticular or extratesticular and solid, cystic, or complex [1]. Cystic extratesticular masses such as spermatoceles or hydroceles are typically benign and have been well described [1]. Inguinal hernias, especially those containing bowel, are diagnosed easily by sonogram. However, a sonogram cannot determine if a solid and complex extratesticular mass is benign or malignant [4].

Using pathologic specimens obtained at Children's Hospital Boston between 1994 and 2004, this pictorial essay reviews the literature and describes common solid and complex extratesticular masses in children, including malignant rhabdomyosarcoma. Based on clinical presentation, masses are divided into two categories: painless and painful.


Painless Masses
Top
 Abstract
 Introduction
 Painless Masses
Painful Scrotal Masses
 Conclusion
 References
 
Rhabdomyosarcoma
Other than paratesticular lipomas found incidentally during surgery, rhabdomyosarcomas were the most commonly resected extratesticular masses in the past 10 years at Children's Hospital Boston. Four percent of these common childhood tumors occur in the paratesticular location [5] (Figs. 1A, 1B, 1C, 2A, and 2B). The embryonal subtype is the most common. Patients typically present with unilateral painless scrotal swelling not associated with fever. With multimodality therapy, the survival after rhabdomyosarcoma resection is reported to be 80% at 3 years [4].


Figure 1
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  		Fig. 1A —4-year-old boy who presented with painless enlargement of right scrotum due to paratesticular rhabdomyosarcoma. Sagittal sonogram of right testicle shows heterogeneous solid mass (arrows) encircling testis (T) separate from epididymis (E). After surgical excision, pathology showed embryonal-type rhabdomyosarcoma.

 

Figure 2
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  		Fig. 1B —4-year-old boy who presented with painless enlargement of right scrotum due to paratesticular rhabdomyosarcoma. Photomicrograph of histopathologic specimen shows highly cellular neoplasm composed of abundant small, round blue cells arranged with lack of cohesive pattern. (H and E, x10)

 

Figure 3
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  		Fig. 1C —4-year-old boy who presented with painless enlargement of right scrotum due to paratesticular rhabdomyosarcoma. Photomicrograph of histopathologic specimen shows tumor, composed of undifferentiated small, round to spindle cells with dark nuclei and scant cytoplasm and interspersed differentiated rhabdomyoblasts with eosinophilic cytoplasm. Tumor cells are surrounded by connective tissue with variable myxoid appearance. (H and E, x60)

 

Figure 4
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  		Fig. 2A —15-year-old boy who presented with enlarging painless right scrotal mass due to rhabdomyosarcoma. Sagittal sonogram shows hypoechoic mass (M) (arrow) that is separate from adjacent testis (T) and compresses epididymis (E). There is increased blood flow to mass by color Doppler (not shown). Surgical excision was performed.

 

Figure 5
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  		Fig. 2B —15-year-old boy who presented with enlarging painless right scrotal mass due to rhabdomyosarcoma. Photomicrograph of histopathologic specimen shows undifferentiated small, round to spindle cells with dark nuclei and scant cytoplasm embedded in connective tissue with focal myxoid appearance. Interspersed are well-differentiated rhabdomyoblasts with eosinophilic cytoplasm. (H and E, x60)

 

Rhabdomyosarcomas vary in appearance from mostly solid to primarily cystic with solid nodules, reflecting the gross pathologic appearance of a solid mass with occasional cystic degeneration and hemorrhage.


Figure 6
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  		Fig. 3A —14-year-old boy with painless right scrotal mass secondary to fibrous pseudotumor. Sagittal sonogram of right scrotum shows hypoechoic mass (M) (arrow) in epididymis that is discrete and separate from testis (T).

 


Figure 7
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  		Fig. 3B —14-year-old boy with painless right scrotal mass secondary to fibrous pseudotumor. Photomicrograph of histopathologic specimen shows granulation tissue composed of capillary-size vessels associated with chronic inflammatory lymphoplasmacytic cell infiltrate in background of focal hyalinized fibrous tissue. (H and E, x40)

 


Figure 8
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  		Fig. 4A —17-year-old boy who presented with firm, mobile, nonpainful left scrotal mass secondary to inflammatory pseudotumor. Sagittal sonogram shows part of normal left testis (T) and large hypoechoic mass (M) (arrow) that is superior to testis. Mass is homogeneous and well defined and has mild peripheral vascular flow on color Doppler evaluation (not shown).

 
Pseudotumor
Fibrous pseudotumor (chronic periorchitis, nodular fibrous periorchitis, and nonspecific paratesticular fibrosis) (Figs. 3A and 3B) and inflammatory pseudotumor (plasma cell granuloma) (Figs. 4A, 4B, and 4C) are benign, reactive, nonneoplastic lesions of the spermatic cord, epididymis, and tunica caused by fibroinflammatory reaction. Patients often have a history of trauma or infection [5].


Figure 9
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  		Fig. 4B —17-year-old boy who presented with firm, mobile, nonpainful left scrotal mass secondary to inflammatory pseudotumor. Photomicrograph of histopathologic specimen shows predominantly collagen-filled stroma in a vaguely nodular pattern with rare interspersed chronic inflammatory cells. There is neither hemorrhage nor necrosis evident. (H and E, x20)

 

Figure 10
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  		Fig. 4C —17-year-old boy who presented with firm, mobile, nonpainful left scrotal mass secondary to inflammatory pseudotumor. Photomicrograph of histopathologic specimen shows associated mixed acute and chronic inflammatory infiltrate encompassing neutrophils, lymphocytes, plasma cells, histiocytes, eosinophils, and occasional mast cells. Within collagenous background are spindle cells without nuclear hyperchromasia or cytologic atypia. (H and E, x20)

 
On a sonogram, both variants of pseudotumor mimic rhabdomyosarcoma, and the diagnosis is rarely made before surgical resection [1]. However, on histologic sections, both lesions look distinctly different. Pseudotumors are commonly associated with hydroceles and hematoceles [5].

Meconium Periorchitis
Meconium periorchitis (meconium granuloma, meconium vaginalitis) (Figs. 5A and 5B) is a very rare masslike lesion that arises as a result of inflammatory reaction from meconium within the scrotal sac. Fewer than 30 cases are described in the literature [6]. In fetal and early postnatal periods, a patent processus vaginalis allows spilled meconium from bowel perforation to spread into the scrotal sac. Consistency and appearance of meconium in the scrotum evolve over time. Soft extratesticular mass at birth eventually hardens and becomes partially calcified [6]. Meconium causes foreign-body giant-cell reaction, chronic inflammation, and finally, scarring. Peritoneal and scrotal calcifications resulting from chronic inflammation are clues to a diagnosis of meconium periorchitis.


Figure 11
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  		Fig. 5A —7-day-old male neonate who presented with severe swelling of scrotum secondary to meconium periorchitis. Transverse sonogram of scrotum shows marked skin thickening and complex fluid collections surrounding testis (T). Multiple echogenic foci with shadowing (arrow) represent calcified meconium.

 

Figure 12
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  		Fig. 5B —7-day-old male neonate who presented with severe swelling of scrotum secondary to meconium periorchitis. Photomicrograph of histopathologic specimen reveals chronically inflamed myxoid stroma with massive accumulation of polymorphonuclear leukocytes and intermixed chronic inflammatory cells and with histiocytes harboring browning meconium pigment in their cytoplasm. (H and E, x40)

 


Figure 13
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  		Fig. 6A —14-year-old boy who presented with hard, mobile, painless scrotal mass secondary to cellular neurofibroma. Transverse sonogram of bilateral testes (T) shows a hypoechoic mass (N) that is discrete from adjacent testicle.

 


Figure 14
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  		Fig. 6B —14-year-old boy who presented with hard, mobile, painless scrotal mass secondary to cellular neurofibroma. Sagittal sonogram of same patient shows hypoechoic paratesticular mass (N) (arrow) with increased flow on color Doppler that is discrete from adjacent testicle (T).

 


Figure 15
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  		Fig. 6C —14-year-old boy who presented with hard, mobile, painless scrotal mass secondary to cellular neurofibroma. Photomicrograph of histopathologic specimen shows elongated, irregularly shaped cells without nuclear atypia. Lesional cells with wavy, dark-staining nuclei are arranged in interlacing bundles, small whorls, and short fascicles. They are embedded in moderate amounts of mucoid or collagenous matrix. Mast cells, lymphocytes, and occasional xanthoma cells are present elsewhere. (H and E, x40)

 
Cellular Neurofibroma
Cellular neurofibroma (Figs. 6A, 6B, and 6C) of the spermatic cord is a rare solid extratesticular mass in adults and children [7]. Neurofibromas arise from nerve cells along the muscularis propria or ensheathing small nerves. This diagnosis should be considered in patients with neurofibromatosis 1 because this disease is associated with an increased incidence of neurofibromas. However, when there is no history of neurofibromatosis and the lesion is solitary, clinical and radiologic findings are nonspecific [7]. These smooth white-to-tan tumors rarely have secondary degenerative changes such as cyst formation or hemorrhage and appear homogeneous on a sonogram.


Painful Scrotal Masses
Top
 Abstract
 Introduction
 Painless Masses
 Painful Scrotal Masses
Conclusion
 References
 
Epididymal Inflammation
Epididymal inflammation leading to chronic epididymitis can be misdiagnosed as rhabdomyosarcoma. Although clinical history and the presence of pain help to differentiate epididymal infection from tumor, the diagnosis is not always clear [8]. Chronic epididymitis may feel and appear masslike (Figs. 7A and 7B), mimicking extratesticular neoplasms.


Figure 16
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  		Fig. 7A —18-year-old man who presented with palpable right scrotal mass and vague right testicular pain for 2 months secondary to chronic epididymitis. Sagittal sonogram of right scrotum shows a solid hypoechoic mass (E) that appears separate from testis (T) and epididymis with increased flow on color Doppler imaging. At inguinal exploration, biopsy of mass and pathology showed chronic epididymitis with fibrosis.

 

Figure 17
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  		Fig. 7B —18-year-old man who presented with palpable right scrotal mass and vague right testicular pain for 2 months secondary to chronic epididymitis. Photomicrograph of histopathologic specimen shows variable numbers of chronic inflammatory cells (i.e., lymphocytes, plasma cells, and histiocytes within collagenized stroma surrounding unremarkable epididymal tubules and ducts). Lymphoid follicles with reactive germinal centers and noncaseating epithelioid granulomas, resulting from sperm-spillage, are seen elsewhere. (H and E, x20)

 


Figure 18
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  		Fig. 8A —15-year-old boy who presented with 1-week history of right groin and scrotal pain due to torsed appendix testis. Parasagittal sonogram shows right testis (T) with adjacent hyperechoic mass (A) without appreciable flow on color Doppler evaluation.

 


Figure 19
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  		Fig. 8B —15-year-old boy who presented with 1-week history of right groin and scrotal pain due to torsed appendix testis. Transverse sonogram of same patient shows heterogeneously echogenic paratesticular mass (A). Although physical examination and sonogram were consistent with torsed appendix testis, patient underwent surgical scrotal exploration.

 
Torsed Appendix
The appendix epididymis and appendix testis are embryologic remnants of the mesonephric (wolffian) duct and paramesonephric (müllerian) duct, respectively [1]. Torsion of these appendages causes acute scrotal pain and a focal bluish discoloration beneath the skin (so-called "blue-dot" sign). A tender nodule is commonly palpated on physical examination [3]. A sonogram (Figs. 8A, 8B, and 8C) typically shows a hyperemic hyperechoic small oval mass adjacent to the testis or epididymis, which may be associated with epididymal inflammation and hydrocele. With time, the torsed appendages involute and may calcify [3].


Figure 20
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  		Fig. 8C —15-year-old boy who presented with 1-week history of right groin and scrotal pain due to torsed appendix testis. Photomicrograph of histopathologic specimen shows marked hemorrhagic infarction and ectatic and congested vascular spaces with leakage and resulting fresh hemorrhage. Scattered hemosiderin pigment-laden macrophages can be found in areas. (H and E, x10)

 


Figure 21
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  		Fig. 9A —4-day-old male neonate who presented with swollen penis and swollen, firm scrotum after circumcision, found to have scrotal abscesses. Sagittal sonogram shows skin thickening and hyperemia of scrotal skin consistent with cellulitis. Complex cystic collection is adjacent to testis (T).

 


Figure 22
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  		Fig. 9B —4-day-old male neonate who presented with swollen penis and swollen, firm scrotum after circumcision, found to have scrotal abscesses. Transverse sonogram shows marked increased flow surrounding testis (T) and adjacent complex fluid collection. At surgery, bilateral scrotal abscesses were incised and drained.

 


Figure 23
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  		Fig. 9C —4-day-old male neonate who presented with swollen penis and swollen, firm scrotum after circumcision, found to have scrotal abscesses. Photomicrograph of histopathologic specimen shows sheets of abundant polymorphonuclear leukocytes and nuclear fragments consistent with abscess. (H and E, x20)

 
Scrotal Abscess
Scrotal abscess (Figs. 9A, 9B, and 9C) can be a complication of epididymoorchitis, trauma, or surgery. The clinical history and physical examination of a painful hyperemic scrotum help in making the diagnosis. On a sonogram, this extratesticular lesion can have a variety of appearances. Areas of infection are generally hyperemic and heterogeneous in echotexture. If organized, an abscess may have a well-defined hyperemic wall. If there is gas within the collection, hyperechoic foci with "dirty" shadowing are seen.


Conclusion
Top
 Abstract
 Introduction
 Painless Masses
 Painful Scrotal Masses
 Conclusion
References
 
Solid or complex extratesticular masses, especially those that present as rapidly growing and painless, may be malignant rhabdomyosarcoma. A history of trauma or acute pain and findings of erythema or tenderness help to distinguish acute inflammatory processes from possibly malignant lesions. Mimickers of rhabdomyosarcoma include chronic inflammatory processes such as pseudotumor, chronic epididymitis, or meconium periorchitis, and less commonly, other tumors. Adenomatoid tumors, common in adults, are rare in children and only one case appeared as an incidental finding in our series. If there is history of neurofibromatosis 1, the extratesticular mass may represent a neurofibroma. Lipomas are commonly found in pathologic specimens but are rarely the cause of the original surgery. Splenogonadal fusion [5] and supernumerary testes [1] are also occasionally diagnosed. Because no pathologically proven cases were reported in our 10-year search, none was included in this article. Although lymphomas have been reported in the literature, none was found in our surgical-pathologic specimens over the past decade.

Because a sonogram cannot distinguish benign from malignant, worrisome extratesticular masses need to be biopsied or removed.


References
Top
 Abstract
 Introduction
 Painless Masses
 Painful Scrotal Masses
 Conclusion
 References
 

  1. Woodward PJ, Schwab CM, Sesterhenn IA. From the archives of the AFIP: extratesticular scrotal masses—radiologic-pathologic correlation. RadioGraphics 2003;23 : 215-240[Abstract/Free Full Text]
  2. Aragona F, Talenti E, Santacatterina U, Perale R, Passerini Glazel G. Unusual, benign asymptomatic scrotal masses in children: case reports and review of the literature. Int Urol Nephrol1994; 26:563 -570[Medline]
  3. Frush DP, Sheldon CA. Diagnostic imaging for pediatric scrotal disorders. RadioGraphics 1998;18 : 969-985[Abstract]
  4. Skoog SJ. Benign and malignant pediatric scrotal masses. Pediatr Clin North Am 1997;44 : 1229-1250[Medline]
  5. Akbar SA, Sayyed TA, Jafri SZ, Hasteh F, Neill JS. Multimodality imaging of paratesticular neoplasms and their rare mimics. RadioGraphics 2003;23 : 1461-1476[Abstract/Free Full Text]
  6. Williams HJ, Abernethy LJ, Losty PD, Kotiloglu E. Meconium periorchitis: a rare cause of a paratesticular mass. Pediatr Radiol 2004; 34:421 -423[Medline]
  7. Jiang R, Chen JH, Chen M, Li QM. Male genital schwannoma: review of 5 cases. Asian J Androl 2003;5 : 251-254[Medline]
  8. Mak CW, Chou CK, Su CC, Huan SK, Chang JM. Ultrasound diagnosis of paratesticular rhabdomyosarcoma. Br J Radiol2004; 77:250 -252[Abstract/Free Full Text]

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