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Pelvis » Scrotum And Testicles
Germ cell tumor testis: NSGCT- embryonal carcinoma
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Presentation A 32 year old male presents with painless left testicular swelling of 2 months duration. There is no history of trauma or fever.
Caption: Transverse image demonstrating both testes.
Description: The right testis appears normal. The left testis is enlarged and shows the presence of an ill-defined, hypoechoic mass replacing a large portion of the normal architecture of the testis and causing a distinct bulge in the contour.
Caption: Transverse view of the left testis.
Description: The left testis showing the hypoechoic mass with irregular margins is noted again. Also seen is an echogenic focus representing calcification within the mass.
Caption: Sagittal image of the testicular mass.
Description: The mass with its irregular lobulated appearance is noted again, with the calcific focus causing posterior acoustic shadowing.
Caption: Power Doppler image of the mass.
Description: The hypoechoic mass demonstrates increased vascularity relative to the flow in the normal portion of the left testis.
Differential Diagnosis Testicular carcinoma
Final Diagnosis Testicular embryonal carcinoma
Discussion Primary testicular carcinomas are histologically classified as germ cell tumors and non-germ cell tumors. The germ cell tumors constitute about 95% of all the tumors, which are further classified as seminomatous [more common] and non-seminomatous germ cell tumors [NSGCT].
1. Seminomatous germ cell tumor

2. Non- seminomatous germ cell tumor [NSGCT]. This category includes:
a. Embryonal cell carcinoma,
b. Yolk sac tumor
c. Mature teratoma
d. Immature teratoma
e. Choriocarcinoma and
f. Endodermal sinus tumor.

The non-germ cell tumors include the Sertoli cell and the Leydig cell tumors.

The embryonal variety of NSGCT, which has been illustrated here has a rapid and bulky growth and metastasizes early. It is commonly seen in the 22-35 age group and the patients present with an enlarged scrotum and pain. High levels of alpha-fetoprotein and beta HCG tumor markers are noted. Ultrasound of the scrotum is a reliable modality to quickly confirm the clinical findings of an intratesticular mass distinguishing it from other extratesticular processes, objectively characterize a palpable testicular tumor or detect an occult testicular primary. Ultrasound can prove helpful in identifying retroperitoneal nodal metastases [although CT and MRI are more commonly performed for this purpose]. Ultrasound also allows for the regular monitoring of these patients while on treatment and after therapy to detect recurrences.

The gray-scale ultrasound features are not very specific for any particular kind of testicular malignancy, but the histological type can sometimes be hypothesized based on certain appearances. The embryonal carcinoma is seen on ultrasound as a large, irregular tumor with loss of the normal architectural contour of the testis. The mass has a heterogeneous appearance, predominantly hypoechoic. It may be seen to infiltrate the tunica albuginea with extension into the spermatic cord structures. Areas of necrosis are seen as cystic spaces within the tumor. Sometimes, areas of hemorrhage and calcification may also be noted as hyperechoic foci.

Color Doppler imaging has a complementary role in the evaluation of testicular tumors. Most of the time, testicular tumors [> 1.6 cm] are hypervascular and this finding can be especially useful if the tumors are isoechoic to the normal testis. Segmental infarction may appear similar to a tumor using gray scale imaging, however, color Doppler can aid in distinguishing it by demonstrating no flow in the infarcted area.

Case References 1. Girl J, Jelinek A. Ultrasonography in the diagnosis of testicular tumors. Cesk Radiol. 1989 Nov; 43(6):383-90.
2. Gerscovich E. High-resolution ultrasonography in the diagnosis of scrotal pathology. II. Tumors. J Clin Ultrasound 1993; 21:375
3. WG Horstman, et al. Testicular tumors: findings with color Doppler US. Radiology 1992. Vol 185, 733-737.
4. Ichijo S. Vascular patterns of testicular tumors: a microangiographic study. J Urol. 1975 Mar; 113(3):360-3.
5. Sriprasad S, et al. Acute segmental testicular infarction: differentiation from tumour using high frequency colour Doppler ultrasound. Br J Radiol. 2001 Oct; 74(886):965-7.
6. Polák V, Hornák M. The value of scrotal ultrasound in patients with suspected testicular tumor. Int Urol Nephrol 1990; 22:467.
7. Luker GD, Siegel MJ. Color Doppler sonography of the scrotum in children. AJR 1994; 163:649.
Follow Up This patient had a radical orchiectomy and chemotherapy. Embryonal carcinoma was confirmed on histopathology.
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