한남성과학회지제 30 권 제 1 호 2012년 4월
Korean J Androl Vol 30 No 1 April 2012
h t t p d x d o i o r g 1 0 5 5 3 4 k j a 2 0 1 2 3 0 1 8 7
87
수일자 2011년 7월 28일 수정일자 (1차) 2011년 9월 20일 (2차) 2011년 9월 27일 (3차) 2011년 10월 10일 게재일자 2011년 10월 12일Correspondence to Du Geon Moon
Department of Urology Korea University Guro Hospital 97 Gurodong-gil Guro-gu Seoul 152-703 KoreaTel 02-2626-3201 Fax 02-2626-1321E-mail dgmoonkoreaackr
Testicular Seminoma Incidentally Detected by Spermatic Cord Torsion
Mi Mi Oh1 Ji Sung Shim1 Sun Tae Ahn1 Tae Yong Park1 Su Hwan Shin1
Suk Cho1 Sang Woo Kim
1 Jong Jin Park
1 Du Geon Moon
12
Department of Urology 1Korea University School of Medicine and 2Korea University Institute of Regenerative Medicine Seoul Korea
= Abstract =
We recently encountered a very rare case of torsion of an intrascrotal testicular tumor in a 26-year-old male Unlike
the intra-abdominal undescended testis intrascrotal spermatic cord torsion associated with a testicular tumor has rarely
been reported We write to report a case of intrascrotal spermatic cord torsion accompanied by a testicular tumor
that had been overlooked preoperatively
985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103Key Words Spermatic cord torsion Seminoma
Torsion usually occurs in the absence of a precipitat-
ing event such as trauma1 Predisposing factors for
testicular torsion are an increase of testicular volume
history of cryptorchidism and testicular tumor2 Most
reports of the spermatic cord torsion associated with
testicular tumors especially seminoma are localized in
the intra-abdominal testis We report this rare case of
intrascrotal spermatic cord torsion associated with an
initially overlooked seminoma for the first time in
South Korea
Case Report
A twenty-six-year-old male patient was referred to
the department of urology from the department of
emergency medicine due to the abrupt onset of left
scrotal pain and swelling He had never noticed en-
largement of scrotum before nor did he have a history
of scrotal pain On physical examination the testis was
enlarged with severe tenderness and the absence of the
cremasteric reflex On gray-scale sonography the tes-
ticle showed heterogeneous echogenicity composed
mainly of a hypoechoic lesion and enlargement of the
epididymis (Fig 1A 1B) Doppler sonography re-
vealed no blood flow We decided to perform emer-
gent detorsion Upon detorsion his pain was relieved
and Doppler sonography showed a resumption of
blood flow The emergency operation planned was bi-
lateral orchiopexy performed through a scrotal midline
incision In the operation room the spermatic cord was
edematous due to prolonged torsion and the enlarged
testicle had bluish mass-like lesions in seminiferous tu-
bules seen through the transparent tunica albuginea
with an enlarged and congested epididymis (Fig 2)
Frozen pathological analysis of the bluish masses dur-
ing operation revealed seminoma An additional in-
guinal incision for an orchiectomy and the final patho-
logical analysis was consistent with seminoma con-
fined to the testis (Fig 3) There was no evidence of
distant metastasis on postoperative abdomino-pelvic
88 한남성과학회지 제 30 권 제 1 호 2012
Fig 1 (A) Gray-scale sonography
showing heterogenous echogenicity
combined with hypoechoic lesions
within the parenchyma (B) Round
shape epididymis without blood
flow on Doppler sonography
Fig 2 Bluish mass like lesions in seminiferous tubules
transparently (white arrow) shown through albuginea with
enlarged and congested epididymis (black arrow)
Fig 3 (A) Hematoxylin and Eosin (HampE) stain revealed tumour cells with abundant clear to pale pink cytoplasm containing
abundant glycogen with fibrous stromal network consistent with seminoma (times400) (B) Histopathology with HampE stain showing
interstitial edema and hemorrhage at epididymis due to prolonged torsion (times100)
computed tomography Alpha-feto-protein was 268
ngml and B-hcg was 270 mlUml Although scrotal
violation was noted the patient refused further treat-
ment and he is being closely monitored
Discussion
Spermatic cord torsion is a well-known emergent
condition that needs prompt restoration of blood flow
by either manual detorsion or surgical exploration The
cryptorchid testicular tumor presenting with spermatic
cord torsion is not a rare condition as several cases
have been reported3 A few cases of testicular tumor
associated with intrascrotal spermatic cord torsion
have been reported4 but this is the first case identified
in South Korea The most commonly used diagnostic
Mi Mi Oh et al Intrascrotal Spermatic Cord Torsion with Seminoma 89
modalities are Doppler ultrasonography and radio-
nuclide imaging but a definite diagnosis can only be
made by surgical exploration We had overlooked the
presence of seminoma in this case for several reasons
A typical sonographic finding of testicular torsion
showed an enlarged testicle with heterogeneous echo-
genicity composed mainly of hypoechoic lesions with-
in the parenchyma5 Also the seminoma which are
usually hypoechoic relative to the normal testis had
a nonspecific ultrasound appearance6 Moreover in-
creases in testicular size can be seen in both testicular
tumors and testicular torsion Due to venous con-
gestion the affected testis may also appear larger than
the unaffected testis7 which may result in overlooking
the coexistence of a testicular tumor as in this case
From our point of view the enlargement of the testicle
can be a key factor for the differential diagnosis of
possible concomitant testicular tumors If we had been
aware of the possibility of a concomitant testicular tu-
mor scrotal violation could have been avoided The
possibility of concomitant testicular tumor must be
considered in patients suspected of spermatic cord tor-
sion if an enlarged testicle with heterogeneous echoge-
nicity is seen on gray-scale sonography
REFERENCES
1) Noumlske HD Kraus SW Altinkilic BM Weidner W
Historical milestones regarding torsion of the scrotal
organs J Urol 199815913-6
2) Arce JD Corteacutes M Vargas JC Sonographic diagnosis
of acute spermatic cord torsion Rotation of the cord
a key to the diagnosis Pediatr Radiol 200232485-91
3) Shirakawa H Kozakai N Sugiura H Hara S Torsion
of a testicular cancer in cryptorchidism prolapsing out
of the inguinal canal a case report Hinyokika Kiyo
200955783-5
4) Takeshita H Chiba K Kitayama S Noro A Two cas-
es of intrascrotal tumors complicated acute scrotum
Nihon Hinyokika Gakkai Zasshi 200899698-702
5) Prando D Torsion of the spermatic cord the main
gray-scale and doppler sonographic signs Abdom
Imaging 200934648-61
6) Vaidyanathan S Hughes PL Mansour P Soni BM
Seminoma of testis masquerading as orchitis in an
adult with paraplegia proposed measures to avoid de-
lay in diagnosing testicular tumours in spinal cord in-
jury patients Scientific World Journal 20088149-56
7) Ringdahl E Teague L Testicular torsion Am Fam
Physician 2006741739-43
88 한남성과학회지 제 30 권 제 1 호 2012
Fig 1 (A) Gray-scale sonography
showing heterogenous echogenicity
combined with hypoechoic lesions
within the parenchyma (B) Round
shape epididymis without blood
flow on Doppler sonography
Fig 2 Bluish mass like lesions in seminiferous tubules
transparently (white arrow) shown through albuginea with
enlarged and congested epididymis (black arrow)
Fig 3 (A) Hematoxylin and Eosin (HampE) stain revealed tumour cells with abundant clear to pale pink cytoplasm containing
abundant glycogen with fibrous stromal network consistent with seminoma (times400) (B) Histopathology with HampE stain showing
interstitial edema and hemorrhage at epididymis due to prolonged torsion (times100)
computed tomography Alpha-feto-protein was 268
ngml and B-hcg was 270 mlUml Although scrotal
violation was noted the patient refused further treat-
ment and he is being closely monitored
Discussion
Spermatic cord torsion is a well-known emergent
condition that needs prompt restoration of blood flow
by either manual detorsion or surgical exploration The
cryptorchid testicular tumor presenting with spermatic
cord torsion is not a rare condition as several cases
have been reported3 A few cases of testicular tumor
associated with intrascrotal spermatic cord torsion
have been reported4 but this is the first case identified
in South Korea The most commonly used diagnostic
Mi Mi Oh et al Intrascrotal Spermatic Cord Torsion with Seminoma 89
modalities are Doppler ultrasonography and radio-
nuclide imaging but a definite diagnosis can only be
made by surgical exploration We had overlooked the
presence of seminoma in this case for several reasons
A typical sonographic finding of testicular torsion
showed an enlarged testicle with heterogeneous echo-
genicity composed mainly of hypoechoic lesions with-
in the parenchyma5 Also the seminoma which are
usually hypoechoic relative to the normal testis had
a nonspecific ultrasound appearance6 Moreover in-
creases in testicular size can be seen in both testicular
tumors and testicular torsion Due to venous con-
gestion the affected testis may also appear larger than
the unaffected testis7 which may result in overlooking
the coexistence of a testicular tumor as in this case
From our point of view the enlargement of the testicle
can be a key factor for the differential diagnosis of
possible concomitant testicular tumors If we had been
aware of the possibility of a concomitant testicular tu-
mor scrotal violation could have been avoided The
possibility of concomitant testicular tumor must be
considered in patients suspected of spermatic cord tor-
sion if an enlarged testicle with heterogeneous echoge-
nicity is seen on gray-scale sonography
REFERENCES
1) Noumlske HD Kraus SW Altinkilic BM Weidner W
Historical milestones regarding torsion of the scrotal
organs J Urol 199815913-6
2) Arce JD Corteacutes M Vargas JC Sonographic diagnosis
of acute spermatic cord torsion Rotation of the cord
a key to the diagnosis Pediatr Radiol 200232485-91
3) Shirakawa H Kozakai N Sugiura H Hara S Torsion
of a testicular cancer in cryptorchidism prolapsing out
of the inguinal canal a case report Hinyokika Kiyo
200955783-5
4) Takeshita H Chiba K Kitayama S Noro A Two cas-
es of intrascrotal tumors complicated acute scrotum
Nihon Hinyokika Gakkai Zasshi 200899698-702
5) Prando D Torsion of the spermatic cord the main
gray-scale and doppler sonographic signs Abdom
Imaging 200934648-61
6) Vaidyanathan S Hughes PL Mansour P Soni BM
Seminoma of testis masquerading as orchitis in an
adult with paraplegia proposed measures to avoid de-
lay in diagnosing testicular tumours in spinal cord in-
jury patients Scientific World Journal 20088149-56
7) Ringdahl E Teague L Testicular torsion Am Fam
Physician 2006741739-43
Mi Mi Oh et al Intrascrotal Spermatic Cord Torsion with Seminoma 89
modalities are Doppler ultrasonography and radio-
nuclide imaging but a definite diagnosis can only be
made by surgical exploration We had overlooked the
presence of seminoma in this case for several reasons
A typical sonographic finding of testicular torsion
showed an enlarged testicle with heterogeneous echo-
genicity composed mainly of hypoechoic lesions with-
in the parenchyma5 Also the seminoma which are
usually hypoechoic relative to the normal testis had
a nonspecific ultrasound appearance6 Moreover in-
creases in testicular size can be seen in both testicular
tumors and testicular torsion Due to venous con-
gestion the affected testis may also appear larger than
the unaffected testis7 which may result in overlooking
the coexistence of a testicular tumor as in this case
From our point of view the enlargement of the testicle
can be a key factor for the differential diagnosis of
possible concomitant testicular tumors If we had been
aware of the possibility of a concomitant testicular tu-
mor scrotal violation could have been avoided The
possibility of concomitant testicular tumor must be
considered in patients suspected of spermatic cord tor-
sion if an enlarged testicle with heterogeneous echoge-
nicity is seen on gray-scale sonography
REFERENCES
1) Noumlske HD Kraus SW Altinkilic BM Weidner W
Historical milestones regarding torsion of the scrotal
organs J Urol 199815913-6
2) Arce JD Corteacutes M Vargas JC Sonographic diagnosis
of acute spermatic cord torsion Rotation of the cord
a key to the diagnosis Pediatr Radiol 200232485-91
3) Shirakawa H Kozakai N Sugiura H Hara S Torsion
of a testicular cancer in cryptorchidism prolapsing out
of the inguinal canal a case report Hinyokika Kiyo
200955783-5
4) Takeshita H Chiba K Kitayama S Noro A Two cas-
es of intrascrotal tumors complicated acute scrotum
Nihon Hinyokika Gakkai Zasshi 200899698-702
5) Prando D Torsion of the spermatic cord the main
gray-scale and doppler sonographic signs Abdom
Imaging 200934648-61
6) Vaidyanathan S Hughes PL Mansour P Soni BM
Seminoma of testis masquerading as orchitis in an
adult with paraplegia proposed measures to avoid de-
lay in diagnosing testicular tumours in spinal cord in-
jury patients Scientific World Journal 20088149-56
7) Ringdahl E Teague L Testicular torsion Am Fam
Physician 2006741739-43