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