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CASE REPORT

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RAPIDLY GROWING ADENOMATOID TUMOR EXTENDINGINTO TESTICULAR PARENCHYMA MIMICS

TESTICULAR CARCINOMA

KAREN EVANS

ABSTRACT40-year-old man presented with a 1-month history of a large, painless, rapidly growing right scrotal mass.

xamination, ultrasonography, and intraoperative inspection did not exclude an intratesticular tumor, and aadical orchiectomy was performed. Histology was typical for adenomatoid tumor, but gross and microscopicnspection revealed bundles of tumor extending from the tunica albuginea into the testicular parenchyma. In thisase the rapid growth, large size, and the inability to exclude an intratesticular origin directed suspicion towardmalignant neoplasm. In hindsight, the tumor’s unique pattern of extension into the adjacent testicular paren-

hyma confounded the preoperative diagnosis. UROLOGY 64: 589.e12–589.e13, 2004. © 2004 Elsevier Inc.

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denomatoid tumors are the most frequentparatesticular tumors. The majority of these

low-growing, small paratesticular masses can beiagnosed by physical examination. Ultrasonogra-hy can further aid the diagnosis of this benignumor by demonstrating the extratesticular loca-ion of the mass. Carmignani et al.1 recently pub-ished a series of incidental benign testicular neo-lasms diagnosed by ultrasound and advocated aestis-sparing approach to these lesions. Althoughdvances in ultrasonography are aiding the charac-erization of scrotal masses, the case presentederein demonstrates that challenges remain in dif-

erentiating between intratesticular and parates-icular masses and between benign and malignantondition on the basis of physical examination,istory, and ultrasonography.

CASE REPORT

A 40-year-old black man was referred to the urol-gy clinic for a 1-month history of an enlarging,ainless right scrotal mass. The patient denied a

he views expressed in this article are those of the author and doot reflect the official policy or position of the Department of thermy, the Department of Defense, or the U.S. Government.From the Department of Urology, Madigan Army Medical Cen-

er, Tacoma, WashingtonAddress for correspondence: MAJ Karen Evans, Department of

rology, Madigan Army Medical Center, Tacoma, WA 98431-100Submitted: March 10, 2004, accepted (with revisions): April

r9, 2004

© 2004 ELSEVIER INC.89.e12 ALL RIGHTS RESERVED

istory of genitourinary disorders, genitourinaryurgery, recent trauma, and constitutional symp-oms. Physical examination revealed a hard, 5-cmass in the inferior aspect of the right testis. A

hest x-ray was normal, and serum tumor markersubsequently returned within normal limits.A scrotal ultrasound confirmed the presence of a

olid, homogenous, 5-cm right scrotal mass. A clearemarcation between the testis and the mass couldot be demonstrated by ultrasonography. The supe-ior portion of the right testis was homogenous, andhe right epididymal head appeared unobstructed.

The patient was taken to the operating room foright testicular exploration. An inguinal incisionas made, and the right spermatic cord was iso-

ated and clamped. The right testis and mass wereelivered and isolated with surgical towels, and theunica was incised. Inspection and palpation local-zed the mass to the inferior testis. The superiorortion of the testis and the epididymal head wereupple. Consideration was given to a testis-sparingpproach. The history of rapid growth, the largeumor size, the inability to demonstrate a clear bor-er between the mass and the testis during ultra-onography, and the localization of the mass to theestis during intraoperative palpation, however,ere most consistent with intratesticular malig-ancy. Because of these findings, a right radicalrchiectomy was performed.Sectioning of the specimen demonstrated a solid,hite mass distorting the architecture of the infe-

ior pole of the testis. Pathologic analysis revealed

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5.5 � 5.5 � 4.0-cm adenomatoid tumor involv-ng the right epididymal tail and testis (Fig. 1). Theistology was typical for an adenomatoid tumornd revealed flattened to cuboidal epithelioid cellsorming trabecula and nest against a stomal back-round containing fibroblast, collagen, and scat-ered chronic inflammatory cells (Fig. 2). Grosslynd microscopically, the tumor was seen extend-ng into the testicular parenchyma.

COMMENT

Adenomatoid tumors are the most commonaratesticular tumors. The majority of adenoma-oid tumors arise in the epididymis; however, theyave been reported in the spermatic cord, prostate,jaculatory duct, and tunica albuginea in men, andn the uterus and fallopian tubes of women.2 Ad-nomatoid tumors are considered benign and areelieved to arise from the mesothelium.

IGURE 1. Inspection during sectioning demonstratedn adenomatoid tumor extending into the testicular pa-enchyma.

IGURE 2. Bundles of tumor cell extending betweenormal seminiferous tubules.

ROLOGY 64 (3), 2004

The majority of adenomatoid tumors can be dis-inguished from intratesticular tumors by their lo-ation upon physical examination and/or imaging.here are several published series characterizing

he ultrasound findings of adenomatoid tumors.3–6

ypically these tumors are 0.5 to 1.5 cm in size,ell circumscribed, homogenous, and localize to

he epididymis or tunica albuginea and can dem-nstrate increase, decrease, or normal flow onoppler ultrasonography. Adenomatoid tumors

rising from the tunica albuginea are reported toemonstrate a well-defined interface between theunical mass and the displaced testicular paren-hyma during ultrasonography. In 1996, Feuer etl.7 published a series of three intratesticular ad-nomatoid tumors, in which the adenomatoid tu-ors were isoechoic or not visible during ultra-

onography. To date, there are no ultrasoundeatures that unequivocally distinguish betweenntratesticular adenomatoid tumors and solid, ma-ignant intratesticular tumors.

This case highlights the difficulty of accurately di-gnosing a paratesticular mass preoperatively whenhe origin of the mass cannot be established beforexcision. Gross and microscopic examination of theumor presented herein demonstrated bundles of tu-or extending into the adjacent testicular paren-

hyma. This unique growth pattern distorted the nor-al testicular architecture and obliterated the border

etween the tunica albuginea and the testis. As a re-ult, an intratesticular mass could not be excluded byltrasonography and palpation. Whereas adenoma-oid tumors arising in the caput frequently extendnto the rete testis and testicular parenchyma, exten-ion of adenomatoid tumors through the tunica is aare occurrence but is thought to have no prognosticignificance.2

REFERENCES1. Carmignani L, Gadda F, Gazzano G, et al: High incidence

f benign testicular neoplasms diagnosed by ultrasound.Urol 170: 1783–1786, 2003.2. Mostofi FK, and Price EB: Tumors of the male genital

ystem, in Firminger HI (Ed): Atlas of Tumor Pathology. Wash-ngton DC, Armed Forces Institute of Pathology, 1973, pp44–151.3. Makarainen HP, Tammela TL, Karttunen TJ, et al: Intra-

crotal adenomatoid tumors and their ultrasound findings.Clin Ultrasound 21: 33–37, 1993.4. Horstman WG, Sands JP, and Hooper DG: Adenomatoid

umor of testicle. Urology 40: 359–361, 1992.5. Kim TJ, Kim SH, Sim JS, et al: Ultrasound findings of an

ntratesticular adenomatoid tumor. J Ultrasound Med 19:27–229, 2000.6. Manson AL: Adenomatoid tumor of the testicular tunica

lbuginea mimicking testicular carcinoma. J Urol 139: 819–20, 1988.7. Feuer A, Dewire DM, and Foley WD: Ultrasound char-

cteristics of testicular adenomatoid tumors. J Urol 155: 174–75, 1996.

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