Diagnostic ultrasound ( PDFDrive )

826 PART III Small Parts, Carotid Artery, and Peripheral Vessel Sonography
A
B
FIG. 22.8 Regressed, or “Burned-Out,” Germ Cell Tumor. (A) Longitudinal scan shows a partly calciied nonviable germ cell tumor in a
patient with retroperitoneal metastases. Notice the hypoechoic mass around the focus of calciication. (B) Contrast-enhanced CT scan in the same
patient shows heterogeneous left retroperitoneal adenopathy (arrow) from regressed primary testicular teratoma.
sex cord–stromal tumor refers to a neoplasm containing Leydig,
Sertoli, thecal, granulosa, or lutein cells and ibroblasts in various
degrees of diferentiation. hese tumors may contain single or
multiple cell types because of the totipotentiality of the gonadal
stroma. 29
he most common type of sex cord–stromal tumor is a Leydig
cell tumor, accounting for 1% to 3% of all testicular neoplasms;
these can occur in any age group, although predominantly in
patients aged 20 to 50 years. 42,43,53 Patients most oten present
with painless testicular enlargement or a palpable mass. Approximately
30% of patients present with an endocrinopathy secondary
to secretions of androgens or estrogens by the tumor, which may
manifest as precocious virilization, impotence, or loss of libido.
he tumor is bilateral in 3% of cases. From 10% to 15% of the
tumors are malignant, having invaded the tunica at diagnosis.
hese gonadal tumors are usually small, solid, homogeneous
hypoechoic masses on sonography and may show mainly
peripheral low on color Doppler imaging (Fig. 22.9A and B). 57
Foci of hemorrhage and necrosis are present in 25% of tumors, 42,53
and thus cystic spaces due to hemorrhage and/or necrosis are
occasionally seen in larger lesions.
Sertoli cell tumors are rare and account for less than 1% of
all testicular tumors; they occur with equal frequency in all age
groups. 58 hey can be of one of three histologic types: Sertoli
cell tumor not otherwise speciied, sclerosing Sertoli cell tumor,
or large cell calcifying Sertoli cell tumor. he most common
presentation is with a painless intratesticular mass. hese tumors
are less likely than Leydig cell tumors to be hormonally active,
although gynecomastia may occur. Sertoli cell tumors may occur
in undescended testes, in patients with testicular feminization,
Klinefelter syndrome, and Peutz-Jeghers syndrome. 59 Sertoli
cell tumors are typically well-circumscribed, unilateral, rounded
to lobulated masses. Occasionally, hemorrhage or necrosis may
occur, giving a more heterogeneous appearance on sonography.
he large-cell calcifying Sertoli cell tumor is a subtype with
distinctive clinical, histologic, and sonographic features. 59 hese
tumors are oten bilateral and multifocal and may be almost
completely calciied. Carney complex, a very rare autosomal
dominant multiple endocrine neoplasia syndrome, is oten
associated with Sertoli cell tumors (Fig. 22.9C).
Additional, less common tumors in this category include
granulosa cell tumors, ibroma-thecomas, and mixed sex
cord–stromal tumors (Fig. 22.9D). Gonadal stromal tumors in
conjunction with germ cell tumors are called gonadoblastomas.
he majority of gonadoblastomas occur in the setting of gonadal
dysgenesis and intersex syndromes. 43,60
Testicular Metastases
Lymphoma and Leukemia
Lymphoma accounts for 5% of all testicular tumors and is the
most common testicular tumor in men older than 60 years, where
it can account for up to 50% of intratesticular masses. However,
testicular involvement occurs in only 1% to 3% of patients with
lymphoma. 29,61 he peak age at diagnosis of lymphoma is 60 to
70 years; 80% of the patients are older than 50 years at diagnosis.
Malignant lymphoma is the most common bilateral testicular
tumor, occurring bilaterally either in a synchronous or, more
oten, in a metachronous manner in up to 38% of cases. 60 One-half
of bilateral testicular neoplasms are lymphoma. 29,42 Most lymphomas
of the testis are B-cell lymphomas, with difuse large
cell lymphoma being the most common. Hodgkin lymphoma
of the testis is extremely rare.
Testicular Metastases
LYMPHOMA
Mostly non-Hodgkin lymphoma
LEUKEMIA
Second most common
Acute leukemia: 40%-65%
“Sanctuary” site
NONLYMPHOMA METASTASES
Lung and prostate most common
Kidney, stomach, colon, pancreas, melanoma