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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 3  |  Issue : 1  |  Page : 70-72

Pseudotumors of paratesticular region mimicking malignancy


1 Department of Pathology, 12 Air Force Hospital, Gorakhpur, Uttar Pradesh, India
2 Department of Surgery, 12 Air Force Hospital, Gorakhpur, Uttar Pradesh, India
3 Department of Radiology, 12 Air Force Hospital, Gorakhpur, Uttar Pradesh, India

Date of Web Publication28-Aug-2013

Correspondence Address:
Deepti Mutreja
Department of Pathology, 12 Air Force Hospital, Air Force Station, Gorakhpur - 273 002, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.117142

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  Abstract 

Fibrous proliferation of testicular tunica also known as fibrous pseudotumor of the testis are are uncommon lesions. These lesions are usually difficult to clinically differentiate from testicular tumors. We describe two cases of pseudotumors of the paratesticular region. The tumors in both cases simulated the appearance of a neoplastic process on gross examination. The first patient presented with a testicular mass while the second presented with acute scrotal abscess. A fibromatous pseudotumor completely encased the testes in both patients. In addition to fibrosis, ossification of the tunica led to "eggshell calcification" on imaging in the first case. Both tumors were successfully resected with an uneventful recovery. Histological examination revealed hypocellular dense collagen bundles with areas of coagulative necrosis with mononuclear inflammatory infiltrate. No evidence of cellular atypia or increased mitosis was seen. There was no tumor recurrence at 15 months follow-up. Fibrous pseudotumors should be considered in the clinical differential diagnosis of testicular and paratesticular masses.

Keywords: Calcification of tunica, paratesticular pseudotumors, scrotal mass


How to cite this article:
Mutreja D, Murali M, Arya A. Pseudotumors of paratesticular region mimicking malignancy. Arch Int Surg 2013;3:70-2

How to cite this URL:
Mutreja D, Murali M, Arya A. Pseudotumors of paratesticular region mimicking malignancy. Arch Int Surg [serial online] 2013 [cited 2024 Mar 19];3:70-2. Available from: https://www.archintsurg.org/text.asp?2013/3/1/70/117142


  Introduction Top


Paratesticular pseudotumors are relatively rare scrotal masses comprising approximately 6% of paratesticular lesions and are accepted as benign, non-neoplastic lesions secondary to trauma, hydrocele, infections or inflammation having a peak incidence in the third decade of life. [1] Calcification of the tunica vaginalis is very rare and reported in only 1% of cases. [2] We herein report two cases of paratesticular pseudotumors in the elderly, one complicated by scrotal pyocele, both presenting as diffusely enlarged testes, that on clinical evaluation were highly suggestive of malignancy.


  Case Reports Top


Case 1

A 77-year-old male presented with a slow growing painless enlargement of right testis of 1 year duration. There was no history suggestive of testicular trauma, orchitis, torsion or previous surgical intervention. Clinical examination revealed large, hard, non-tender, non-transilluminant testicular mass in the right scrotum. His abdomen was soft with no organomegaly or palpable masses and inguinal region was unremarkable. An ultrasound (US) evaluation of the scrotum showed circumferential enlarged testis measuring 10.4 cm × 6.6 cm × 4.8 cm. Dense areas of peripheral calcification with hypoechoic areas and multiple intraparenchymal calcifications were seen [Figure 1]a. Sonologic diagnosis of testicular malignancy was considered. Patient was evaluated with a contrast enhanced computed tomography of the abdomen and scrotum, which showed large space occupying lesion in the right scrotum with thick eggshell peripheral calcification [Figure 1]b. Serum alpha-fetoprotein, beta human chorionic gonadotropin and serum lactate dehydrogenase levels were within the normal limits. Fine needle aspiration of the testicular mass performed after taking informed consent caused near bending of the 23 gauge needle, and, revealed acellular necrotic debris only. With a clinical diagnosis of testicular tumor, an inguinal orchiectomy was performed. On gross examination, a diffusely enlarged right testis measuring 10 cm × 6.5 cm × 3.5 cm was found. Cut surface showed circumferentially thickened and ossified tunica with central necrotic liquefied debris [Figure 1]c and d. The necrotic material was sterile on culture. Histological examination revealed markedly thickened fibrotic tunica with calcification [Figure 2]a and focal cholesterol granulomas with an extremely atrophic hyalinized testis [Figure 2]b. No tuberculous granuloma, parasites, cellular atypia or increased mitosis were seen. Postoperative follow-up was uneventful.
Figure 1: (A) Sonography, (B) contrast enhanced computed tomography scan showing circumferential eggshell like calcific testicular tunica. (C) Cut surface of fixed specimen of testis showing diffuse circumferentially thickened and ossified tunica. (D) Necrotic liquefied debris drained per operatively

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Figure 2: (A) Histology showing densely calcific tunica (H and E, ×100); inset showing blackish calcium deposits (Von Kossa stain, ×400). (B) Atrophic hyalinized testis (H and E, ×400)

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Case 2

A 68-year-old male presented with pain and redness of the right scrotum of 10 days duration. He had been diagnosed of idiopathic bilateral hydrocoele for 3 years. Physical examination revealed an elderly man who was febrile and having an acutely painful, swollen hyperemic and congested right scrotum with oozing of pus. No testicular mass could be palpated as local pain; swelling and hyperemia limited evaluation of the testis. Full blood count showed an elevated white blood cell count. With a clinical diagnosis of scrotal abscess the patient was treated with adequate analgesia and empirical antibiotics. Incision and drainage of the abscess under spinal anesthesia was performed. Intra-operatively, pus was found in the hemiscrotum and an enlarged hard right testis was discovered. With a suspicion of malignancy, a right sided orchidectomy was performed after obtaining the consent. Gross appearance of the mass showed diffusely enlarged right testis measuring 9 cm × 6.5 cm × 4 cm. Cut surface showed testis compressed by circumferential whitish fibrous band like growth, more toward upper pole of the testis. Central area of cavitation and hemorrhage was seen at the upper pole [Figure 3]a. Histological examination revealed hypocellular dense collagen bundles [Figure 3]b. Section through the hemorrhagic area showed coagulative necrosis with mononuclear inflammatory infiltrate. The epididymis was not identified in sections. No evidence of cellular atypia or increased mitosis was seen. Patient had an uneventful recovery and continues to be healthy at 15 months follow-up.
Figure 3: (A) Testis compressed by circumferential whitish fibrous band like growth, with area of cavitation and hemorrhage at the upper pole. (B) Histology showing paucicellular fibroblastic proliferation with thin-walled blood vessels and interspersed chronic inflammatory cells (H and E, ×400)

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  Discussion Top


Fibrous pseudotumor is an uncommon lesion known by a host of names, including nodular fibrous periorchitis; reactive periorchitis; fibrous mesothelioma and has a peak incidence in the third decade of life but can occur at any age. [1],[2] Most patients present with a painless scrotal mass, but they often have a history of prior infection or trauma, which supports a reactive pathogenesis. These masses can be quite large and mimic neoplasms [1] as in both of our patients. Calcification of the tunica vaginalis is very rare and is usually seen in elderly males with chronic hydrocoele possibly due to secondary irritation or secondary to filariasis. [3]

Fibrous pseudotumors have been classified as macroscopic mimickers of testicular and paratesticular neoplasia. [4] Based on the histopathologic findings, two categories of paratesticular pseudoneoplastic proliferations were proposed, namely inflammatory and fibrous pseudotumors. [5] A three tier classification namely plaque-like type, an inflammatory or sclerotic type and a myofibroblastic type, based on differences in their amount of collagen, capillaries and inflammatory component has also been proposed. [6] The majority of paratesticular inflammatory pseudotumors and fibrous pseudotumors nowadays are thought to represent the same lesion in various stages of development, with a predominance of inflammation and myofibroblastic proliferation in early lesions, to heavily collagenized, paucicellular fibrous nodules in more advanced stages. [5],[6] Both patients in our study were elderly males with a history of longstanding hydroceles. Dense fibrosis was seen in both cases and extensive calcification to the extent of ossification was seen in the first case. There was however no associated trauma, torsion or orchitis. It is possible that an unnoticed minor trauma may have caused a hematocele, which may have led to testicular infarction and necrosis associated with calcification of tunica in the first case. The fibrosis may have followed a chronic irritant stimulus of the long standing hydrocele in the second case.

The fibrous pseudotumors have variable non-specific appearances on US. A definite diagnosis of the fibrous pseudotumor cannot be made preoperatively due to non-specific features. [1] US appearance of a cluster of calcification, when seen in association with a hypoechoic area in the testis, suggests a testicular tumor or chronic testicular infarction. The distinction between focal infarction and tumor may be difficult. Infarction may be due to trauma or may develop secondary to severe epididymitis. [7] The second case in our study too had shown calcification with associated hypoechoic areas on US evaluation causing a suspicion of malignancy.

Testicular sparing surgeries are not possible in most of the cases especially in cases of fibromatous periorchitis. The best treatment is scrotal exploration of the mass and frozen section biopsy. [8] Our patients were also managed with surgical excision of the testis and histopathological analysis confirmed the benign nature of the lesions. Although a relatively rare disease, a fibrous pseudotumor should be considered in the clinical differential diagnosis of testicular and paratesticular tumors, more so, because cellular lesions need to be differentiated from sarcomas and spindle cell mesotheliomas. If testicular tumor cannot be excluded with certainty, radical orchidectomy is the procedure of choice.

 
  References Top

1.Ugras S, Yesil C. Fibrous pseudotumors of tunica albuginea, tunica vaginalis and epididymis: Report of two cases. Cancer Epidemiol 2009;33:69-71.  Back to cited text no. 1
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2.Namjoshi SP. Calculi in hydroceles: Sonographic diagnosis and significance. J Clin Ultrasound 1997;25:437-41.  Back to cited text no. 2
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3.Lau MW, Pantelides ML. Calcified hydrocele in a young man. BJU Int 1999;83:877.  Back to cited text no. 3
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4.Algaba F, Mikuz G, Boccon-Gibod L, Trias I, Arce Y, Montironi R, et al. Pseudoneoplastic lesions of the testis and paratesticular structures. Virchows Arch 2007;451:987-97.  Back to cited text no. 4
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5.Bösmüller H, von Weyhern CH, Adam P, Alibegovic V, Mikuz G, Fend F. Paratesticular fibrous pseudotumor - An IgG4-related disorder? Virchows Arch 2011;458:109-13.  Back to cited text no. 5
    
6.Miyamoto H, Montgomery EA, Epstein JI. Paratesticular fibrous pseudotumor: A morphologic and immunohistochemical study of 13 cases. Am J Surg Pathol 2010;34:569-74.  Back to cited text no. 6
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7.Bushby LH, Miller FN, Rosairo S, Clarke JL, Sidhu PS. Scrotal calcification: Ultrasound appearances, distribution and aetiology. Br J Radiol 2002;75:283-8.  Back to cited text no. 7
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8.Tobias-machado M, Corrêa Lopes Neto A, Heloisa Simardi L, Borrelli M, Wroclawski ER. Fibrous pseudotumor of tunica vaginalis and epididymis. Urology 2000;56:670-2.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


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