Downloaded from www.ajronline.org by SUNY Downstate Medical Center on 03/20/15 from IP address 138.5.159.110. Copyright ARRS. For personal use only; all rights reserved
i 057
Testicular
Microlithiasis:
Sonographic
and Clinical
Features
.
Dennis L. Janzen1 John R. Mathieson1 J. Ian Marsh1 Peter L. Cooperberg1 Pedro del Rio1 Ross H. Golding2 Matthew D. Rifkin3
Eleven
cases
of bilateral
diffuse
graphically. The presence of testicular neoplasms (n (n = 2), subfertility (n = 2), (n = 1), scrotal trauma (n
microlithiasis
of the testes
were evaluated
sono-
of testicular microlithiasis was coincidental to the presence = 2), nontesticular malignant lesion in the abdomen or chest vancocele (n = 1), epididymitis (n = 1), testicular maldescent = 1), and transient scrotal pain (n = 1). Clinical follow-up
suggested that testicular microlithiasis is an asymptomatic nonprogressive condition. Sonographic examination of testicular microlithiasis shows diffuse hyperechoic nonshadowing foci measuring 1-2 mm in diameter throughout both testes. The diagnosis of testicular
diagnosis information
microlithiasis
was
pathologically
proved
in five
cifications (n = 3). The sonographic appearance of testicular microlithiasis that biopsy or orchiectomy in these cases is unnecessary. 158:1057-1060,
AJR
cases.
In six cases,
the
was made on the basis of the sonographic appearance (n = 6), clinical and follow-up (n = 6), and radiologic demonstration of testicular microcal-
May
is specific,
and we believe
1992
Testicular sonography is a well-accepted method of assessing testicular abnormalities. Sonography reveals homogeneous medium-level echogenicity in the normal testis. Foci of increased echogenicity may be seen in the mediastinum testis owing to invagination of the tunica albuginea and testicular vessels [1]. Focal echogenicities are occasionally seen in the testicular parenchyma; these are typically few in number and are usually due to spermatic granulomas, isolated intraluminal calcifications, or phleboliths [1 2]. Larger diffusely hyperechoic testicular masses may represent benign processes such as fibrosis or granulomas [3, 4]. The presence of innumerable tiny echogenic foci throughout the testicle is uncommon. We present the sonographic and clinical findings in 1 1 patients in whom sonography showed innumerable tiny echogenic foci (“speckles”) throughout both testes and in whom pathologic examination or clinical follow-up was consistent with the diagnosis of testicular microlithiasis (TM). ,
Materials Received September 30, 1991 : accepted revision December 12, 1991.
after
I Department of Radiology, University of British Columbia and St. Paul’s Hospital, 1 081 Burrard St., vancouver, B.C., Canada V6Z 1 Y6. Address reprint
Reno Diagnostic
Center,
590 Eureka
St., Aeno,
NV 895i2. 3 Department of Radiology, Albany Medical Colloge, 47 New Scotland Ave., Albany, NY 12208.
o36i-8o3x/92/i C American
585-1057 Roentgen
and
analyzed
diffusely patients, curved
Ray Society
Methods retrospectively
the
medical
records
and
sonographic
images
of
bilateral
speckled testes of 1 i patients seen at our institutions from 1 980 to i 991 . In all testicular sonography was performed with 7.5-MHz or iO-MHz linear-array and linear-array
testicular
requests to J. A. Mathieson. 2
We
transducers,
radiographs
using commercially
in three
patients,
using
available
standard
imaging
systems.
mammographic
We obtained
equipment
and
techniques.
In five cases, pathologic material was available, either from or from testicular biopsy (n = 1). Clinical follow-up was obtained from
the primary
physician
and/or
symptoms or signs of testicular 49 months.
urologist.
orchiectomy
(n
=
4)
clinically
six patients assessed for any
of clinical follow-up
ranged from i 4 to
The patients
disease. The duration
unilateral
were
in the remaining
.
1058
JANZEN
Downloaded from www.ajronline.org by SUNY Downstate Medical Center on 03/20/15 from IP address 138.5.159.110. Copyright ARRS. For personal use only; all rights reserved
-
-‘-
-..
Results The patients were 1 0-35 years old (mean, 28 years). The clinical indications for testicular sonography were the presence of an abdominal mass (n = 2), mediastinal and neck masses (n = 1), subfertility (n = 2), scrotal pain (n = 2), varicocele (n = 1), undescended testis (n = 1), scrotal trauma (n = 1), and a palpable mass in the testis (n = i). None of the patients had undergone testicular sonography previously. In all patients, sonography showed a diffuse bilateral speckled appearance in the testes studied. The hyperechoic foci were i - to 2-mm in diameter and were randomly distributed throughout both testes. Profusion of the hyperechoic
foci was
variable
(Fig.
i),
and
no acoustic
shadowing
was
seen. The size and contour of the testes were normal, and the epididymis was normal except in one patient with epididymitis. No scrotal skin thickening or significant hydrocele was present. Use of a 7.5-MHz or 1 0-MHz transducer provided optimal visualization of the hyperechoic foci. Testicular radiography with mammography equipment was performed in three patients to confirm the presence of diffuse bilateral microcalcifications. In two patients, sonography showed focal hypoechoic testicular masses, with diffuse speckled echogenic foci seen throughout both the uninvolved portions of the testicle and the entire contralateral testicle (Fig. 2). One of these patients presented with an abdominal mass, and pathologic findings Showed seminoma and TM in the nonseminomatous portion of the testis. Pathologic results indicated that the patient with a palpable intratesticular TM in the nonseminomatous
mass
had
a seminoma
as well
as
portion of the testis. The presence of TM did not impair sonographic detection or evaluation Of the hypoechoic testicular neoplasms. Orchiectomy and pathologic examination revealed testicular microlithiasis with no evidence of malignant lesions in one of the patients who had an abdominal mass. Left testicular biopsy and pathologic examination showed TM with no evidence of malignant lesions in the patient who had neck and mediastinal masses. The neck and mediastinal masses
ET
.:
AL.
a---
AJR:i58,
May 1992
Fig. 1.-Testicular microlithiasis. Sonograms from two diflerent patients (A and B) show the typical speckled appearance of testicular microlithiasis. Multiple 1- to 2-mm hyperechoic foci are present diffusely throughout testes. The profusion of these foci is variable.
-
were subsequently proved to contain large noncleaved cell lymphoma. This patient had a history of right testicular maldescent resulting in right orchiectomy at age 8. No focal hypoechoic region was found in either of these patients on testicular sonography. Semen analysis and sperm motility studies were normal in the two patients with subfertility. One of the patients with scrotal pain had epididymal swelling and tenderness, which is consistent with epididymitis; in the second patient with scrotal pain, no cause was found. Sonograms of the patient who had had scrotal trauma showed TM; however, this diagnosis was not recognized. A unilateral orchiectomy was performed to evaluate the testes; pathologic examination showed TM. A left scrotal varicocele was seen in one patient. In another patient with an undescended left testis in the inguinal canal, sonograms showed hyperechoic foci, which were
more
numerous
in the
undescended
left testis
than
in
the normally descended right testis. Pathologic specimens were available in five patients. Intratubular concentrically lamellated calcified bodies typical of TM were found in all cases (Fig. 3). No histologic evidence of inflammation or granulomatous disease was found.
Discussion Testicular microlithiasis is an uncommon and nonprogressive entity that is typically discovered as an incidental finding during investigation of unrelated testicular symptoms [5]. Three previous cases have been reported in the Englishlanguage sonographic literature [5-7], and a series of five patients (three with histologic proof) has been reported in the Spanish-language literature [8]. Nine cases of pathologically proved TM without sonographic examination have been reported [9-i 6], and one study of autopsy specimens found testicular intraluminal calcifications in 0.05% of boys [i i]. Histologic examination is probably more sensitive than sonography in detecting TM.
Downloaded from www.ajronline.org by SUNY Downstate Medical Center on 03/20/15 from IP address 138.5.159.110. Copyright ARRS. For personal use only; all rights reserved
AJR:i58,
TESTICULAR
May 1992
MICROLITHIASIS
1059
Fig. 2.-Longitudinal sonogram shows a hypoechoic region (arrow) representing seminoma. The remainder of the testis contains tiny hyperechoic foci typical of testicular microlithiasis.
Fig. 3.-Photomicrograph
of involved
testicle
shows concentrically lamellated calcific concretion (arrow) within Iumina of seminiferous tubules. (H and E stain, original magnification xlOO)
The sonographic appearance of TM is characteristic. Innumerable tiny bright foci, measuring less than 2 mm in diameter, are present diffusely throughout both testes. Acoustic shadowing is not seen, probably because of the small size of the calcifications. The hyperechoic foci correspond to the microcalcifications seen on testicular radiography and pathologic examination. There are no associated abnormalities in the epididymis or scrotal skin. Unilateral TM has not been described. The sonographic appearance of TM in our series is identical to that in previously reported cases [5-7, i 7], two of which describe the same patient [6, i 7]. Multiple hyperechoic regions may be seen on testicular sonography owing to calcified granulomas or focal scars; in these cases, the hyperechoic regions are larger and less numerous than those of TM [6]. Calcifications due to previous trauma or infection may be found in the epididymis or tunica vaginalis testis [4]. Solitary hyperechoic testicular masses can be caused by scar tissue, fibrosis, or benign adenomatoid tumors [3]. Hyperechoic regions can also be seen in the testicle as a result of orchitis [i], sarcoidosis [i8, i 9], or chronic infarction [i 9]; however, these hyperechoic regions are larger
and less well defined
than those
seen
in TM.
Solitary
hyperechoic regions greater than 5 mm in diameter have been described in nonviable primary testicular germ cell tumors [20], in intratesticular lipoma [2i], and in a benign fibrous intratesticular mass [4]. Recent reviews of the sonographic appearance of diffuse infiltrating testicular diseases do not describe a speckled appearance [22, 23]. The diffuse speckled appearance seen in TM has not been described in association with any other testicular abnormality. Histologic examination of the diffusely speckled testicle has invariably documented the presence of TM [5-9, i 7]. We believe
that
this speckled
sonographic
appearance
is specific
to TM, and therefore biopsy or excision in these cases is unnecessary. Testicular radiography may be useful to confirm the presence of intratesticular calcifications [9]. The hyperechoic foci seen on sonography represent calcifled concretions within the lumina of the seminiferous tubules
[5-7,
9-i
6, 24].
These
concretions
are formed
from
degen-
erating tubular epithelial cells, which slough into the tubule lumina. Lamellated concentric layers of collagenous material form within the tubule lumina, and this material serves as a site for dystrophic calcification [i 0]. Luminal obstruction can occur, and as many as 30-40% of the seminiferous tubules may be involved [iO]. TM is frequently associated with cryptorchidism or delayed testicular descent [5, 6, 9-i i J; however, the precise incidence of TM in this group is not known. Of the 23 cases reported in the English-language literature and in the present series, nine were associated with cryptorchidism or delayed descent of the testicle. TM has been found at histologic examination in two of 30 patients with cryptorchidism [i 0]. Associations have also been reported between TM and Klinefelter’s syndrome [i 2, i 3], male pseudohermaphroditism [i 2], Down’s syndrome [i 2], and pulmonary alveolar microlithiasis [i 4]. TM also has been associated with subfertility/mnfertility [8, is, 24]. Oligospermia or azoospermia has been documented in three patients [8]; the two subfertile patients in our series had normal semen analyses. The cause of subfertility in TM patients has not been clearly established. Subfertility and TM may both be sequelae of testicular maldescent. TM and testicular neoplasm can coexist. A case of malignant germ cell tumor [7] and two cases of seminoma in our series have been described in association with TM. The presence of TM did not impair sonographic diagnosis of the tumors. TM does not appear to be strongly associated with testicular neoplasm: none of the patients in our series developed clinically apparent testicular neoplasms during the follow-up period. However, this entity is associated with testicular maldescent and infertility, conditions that do carry an increased risk of testicular neoplasm. Since the risk of subsequent malignancy in testicular microlithiasis is unknown, clinical or sonographic surveillance of patients with TM may be prudent [7]. In summary, TM is an uncommon asymptomatic abnormality with a characteristic sonographic appearance. Patients’
Downloaded from www.ajronline.org by SUNY Downstate Medical Center on 03/20/15 from IP address 138.5.159.110. Copyright ARRS. For personal use only; all rights reserved
1060
JANZEN
symptoms should not be attributed to the presence of TM; unrelated abnormalities should be sought. This condition can be associated with genetic and urologic abnormalities. The finding of bilateral speckled testes on sonography establishes the diagnosis of TM; therefore, biopsy or excision in these cases is unnecessary.
ACKNOWLEDGMENTS We thank D. A. Stringer (British Columbia’s Children’s Hospital, B.C.), R. Pitman (Squamish General Hospital, Squamish, B.C.), and A. A. List (Auckland Public Hospital, Auckland, New Zealand) for providing cases. Vancouver,
REFERENCES 1 . Krone
KD,
Carroll
BA.
Scrotal
1985:23: 121 -1 39 2. Doherty FJ. (Jtrasound of the 1991;12: 131 -156 3. Vick CW, Bird KI Jr, Rosenfield
masses 4. 5. 6.
7.
with
a uniformly
ultrasound. nonacute
Radiol
scrotum.
Clin Semin
North
Am
US CT MR
AT, Viscomi GN, Taylor KJW. Scrotal hyperechoic pattern. Radiology 1983:148:
ET
AL.
AJR:158,
May 1992
8. MacKinnon J, Coz F, Diaz L. Testicular microlithiasis: echographic diagnosis of a new cause of orchialgia and infertility. Rev Chil Obstet Ginecol 1990:55:6-9 9. Weinberg AG, Currarino Pathol 1973:95:312-319 10. vegni-Talluri M, Bigliardi
G, Stone E, Vanni
IC Jr. Testicular MG, Tota
microlithiasis.
G. Testicular
Arch
microliths:
their
origin and structure. J Urol 1980:124: 105-i 11 ii . Nistal M, Paniagua A, Diez-Pardo JA. Testicular microlithiasis in two children with bilateral cryptorchidism. J Urol 1979:12i :535-538 i2. Bieger AC, Passarage E, McAdams AJ. Testicular intratubular bodies. J Clin Endocrinol Metab 1965:25: 1340-i 343 13. Lanman JT, Sklarkin BS, Cooper HL. Klinefelter’s syndrome in a ten month old mongolian idiot: report of a case with chromosomal analysis. N Eng! J Med 1960:263:887-892 1 4. Coetzee T. Pulmonary alveolar microlithiasis with involvement of the sympathetic nervous system and gonads. Thorax 1970;25:637-639 1 5. Schantz A, Milsten A. Testicular microlithiasis with sterility. Fertll Steril 1976:27:801-804 16. Priebe CJ Jr, Garret A. Testicular calcifications in a four year old boy. Pediatrics 1970:46:785-786 17. Mullins TL, Sant GA. Ucci AA, Doherty FJ. Testicular microlithiasis occurring in a post-orchiopexy testis. Urology 1986:27: i44-i47 i8. McAlister WH, Sisler CL. Scrotal sonography in infants and children. Curr Probl Diagn Radiol 1990:19:219-222 19. Blei L, Sihelnik 5, Bloom D, Stutzman A, Chiadis J. LJtrasonographic analysis of chronic intratesticular pathology. J Ultrasound Med 1983:2:
17-23
20.
209-211 Lipinski JK, Rao CA. Ljtrasound diagnosis of a benign calcified testicular mass: report of a case. J Can Assoc Radiol 1986:37: 1 1 2-i 13 Jaramillo D, Perez-Atayde A, Teele AL. Sonography of testicular microlithiasis. Urol Radiol 1989:11:SS-S9 Doherty FJ, Mullins TL, Sant GA, Drinkwater MA, Ucci AA. Testicular microlithiasis: a unique sonographic appearance. J Ultrasound Med 1987:6:389-391 Kragel PJ, Delvecchio D, Orlando A, Garvin DF. (Jtrasonographic finding
Shawker TH, Javadpour N, O’Leary T, Shapiro E, Krudy AG. Ultrasonic detection of “burned-out” primary testicular germ cell tumors in clinically normal testes. J Ultrasound Med 1983:2:277-279 21 . Hertzberg BS, Mahony BS, Bowie JD, Anderson EE. Sonography of an intratesticular liporna. J Ultrasound Med 1985:4:619-621 22. Subramanyan BA, Hon SC, Hilton S. Diffuse testicular disease: sonographic features and significance. AJR 1985:145: 1221 -1 224
of testicular microlithiasis
24.
Urology
1991:37:66-68
associated with intratubular
gem, cell neoplasia.
23. Aifkin MD, Kurtz AB, Pasto ME, et al. The sonographic and diffuse infiltrating Sasgawa I, Nakada
Testicular
diagnosis of focal
intrascrotal lesions. Urol Radiol 1984;6:20-26 T, Kazama T, Satomi 5, Katayama T, Matuda microlithiasis in male infertility. Urolint 1988:43:368-369
S.
i 057
Testicular
Microlithiasis:
Sonographic
and Clinical
Features
.
Dennis L. Janzen1 John R. Mathieson1 J. Ian Marsh1 Peter L. Cooperberg1 Pedro del Rio1 Ross H. Golding2 Matthew D. Rifkin3
Eleven
cases
of bilateral
diffuse
graphically. The presence of testicular neoplasms (n (n = 2), subfertility (n = 2), (n = 1), scrotal trauma (n
microlithiasis
of the testes
were evaluated
sono-
of testicular microlithiasis was coincidental to the presence = 2), nontesticular malignant lesion in the abdomen or chest vancocele (n = 1), epididymitis (n = 1), testicular maldescent = 1), and transient scrotal pain (n = 1). Clinical follow-up
suggested that testicular microlithiasis is an asymptomatic nonprogressive condition. Sonographic examination of testicular microlithiasis shows diffuse hyperechoic nonshadowing foci measuring 1-2 mm in diameter throughout both testes. The diagnosis of testicular
diagnosis information
microlithiasis
was
pathologically
proved
in five
cifications (n = 3). The sonographic appearance of testicular microlithiasis that biopsy or orchiectomy in these cases is unnecessary. 158:1057-1060,
AJR
cases.
In six cases,
the
was made on the basis of the sonographic appearance (n = 6), clinical and follow-up (n = 6), and radiologic demonstration of testicular microcal-
May
is specific,
and we believe
1992
Testicular sonography is a well-accepted method of assessing testicular abnormalities. Sonography reveals homogeneous medium-level echogenicity in the normal testis. Foci of increased echogenicity may be seen in the mediastinum testis owing to invagination of the tunica albuginea and testicular vessels [1]. Focal echogenicities are occasionally seen in the testicular parenchyma; these are typically few in number and are usually due to spermatic granulomas, isolated intraluminal calcifications, or phleboliths [1 2]. Larger diffusely hyperechoic testicular masses may represent benign processes such as fibrosis or granulomas [3, 4]. The presence of innumerable tiny echogenic foci throughout the testicle is uncommon. We present the sonographic and clinical findings in 1 1 patients in whom sonography showed innumerable tiny echogenic foci (“speckles”) throughout both testes and in whom pathologic examination or clinical follow-up was consistent with the diagnosis of testicular microlithiasis (TM). ,
Materials Received September 30, 1991 : accepted revision December 12, 1991.
after
I Department of Radiology, University of British Columbia and St. Paul’s Hospital, 1 081 Burrard St., vancouver, B.C., Canada V6Z 1 Y6. Address reprint
Reno Diagnostic
Center,
590 Eureka
St., Aeno,
NV 895i2. 3 Department of Radiology, Albany Medical Colloge, 47 New Scotland Ave., Albany, NY 12208.
o36i-8o3x/92/i C American
585-1057 Roentgen
and
analyzed
diffusely patients, curved
Ray Society
Methods retrospectively
the
medical
records
and
sonographic
images
of
bilateral
speckled testes of 1 i patients seen at our institutions from 1 980 to i 991 . In all testicular sonography was performed with 7.5-MHz or iO-MHz linear-array and linear-array
testicular
requests to J. A. Mathieson. 2
We
transducers,
radiographs
using commercially
in three
patients,
using
available
standard
imaging
systems.
mammographic
We obtained
equipment
and
techniques.
In five cases, pathologic material was available, either from or from testicular biopsy (n = 1). Clinical follow-up was obtained from
the primary
physician
and/or
symptoms or signs of testicular 49 months.
urologist.
orchiectomy
(n
=
4)
clinically
six patients assessed for any
of clinical follow-up
ranged from i 4 to
The patients
disease. The duration
unilateral
were
in the remaining
.
1058
JANZEN
Downloaded from www.ajronline.org by SUNY Downstate Medical Center on 03/20/15 from IP address 138.5.159.110. Copyright ARRS. For personal use only; all rights reserved
-
-‘-
-..
Results The patients were 1 0-35 years old (mean, 28 years). The clinical indications for testicular sonography were the presence of an abdominal mass (n = 2), mediastinal and neck masses (n = 1), subfertility (n = 2), scrotal pain (n = 2), varicocele (n = 1), undescended testis (n = 1), scrotal trauma (n = 1), and a palpable mass in the testis (n = i). None of the patients had undergone testicular sonography previously. In all patients, sonography showed a diffuse bilateral speckled appearance in the testes studied. The hyperechoic foci were i - to 2-mm in diameter and were randomly distributed throughout both testes. Profusion of the hyperechoic
foci was
variable
(Fig.
i),
and
no acoustic
shadowing
was
seen. The size and contour of the testes were normal, and the epididymis was normal except in one patient with epididymitis. No scrotal skin thickening or significant hydrocele was present. Use of a 7.5-MHz or 1 0-MHz transducer provided optimal visualization of the hyperechoic foci. Testicular radiography with mammography equipment was performed in three patients to confirm the presence of diffuse bilateral microcalcifications. In two patients, sonography showed focal hypoechoic testicular masses, with diffuse speckled echogenic foci seen throughout both the uninvolved portions of the testicle and the entire contralateral testicle (Fig. 2). One of these patients presented with an abdominal mass, and pathologic findings Showed seminoma and TM in the nonseminomatous portion of the testis. Pathologic results indicated that the patient with a palpable intratesticular TM in the nonseminomatous
mass
had
a seminoma
as well
as
portion of the testis. The presence of TM did not impair sonographic detection or evaluation Of the hypoechoic testicular neoplasms. Orchiectomy and pathologic examination revealed testicular microlithiasis with no evidence of malignant lesions in one of the patients who had an abdominal mass. Left testicular biopsy and pathologic examination showed TM with no evidence of malignant lesions in the patient who had neck and mediastinal masses. The neck and mediastinal masses
ET
.:
AL.
a---
AJR:i58,
May 1992
Fig. 1.-Testicular microlithiasis. Sonograms from two diflerent patients (A and B) show the typical speckled appearance of testicular microlithiasis. Multiple 1- to 2-mm hyperechoic foci are present diffusely throughout testes. The profusion of these foci is variable.
-
were subsequently proved to contain large noncleaved cell lymphoma. This patient had a history of right testicular maldescent resulting in right orchiectomy at age 8. No focal hypoechoic region was found in either of these patients on testicular sonography. Semen analysis and sperm motility studies were normal in the two patients with subfertility. One of the patients with scrotal pain had epididymal swelling and tenderness, which is consistent with epididymitis; in the second patient with scrotal pain, no cause was found. Sonograms of the patient who had had scrotal trauma showed TM; however, this diagnosis was not recognized. A unilateral orchiectomy was performed to evaluate the testes; pathologic examination showed TM. A left scrotal varicocele was seen in one patient. In another patient with an undescended left testis in the inguinal canal, sonograms showed hyperechoic foci, which were
more
numerous
in the
undescended
left testis
than
in
the normally descended right testis. Pathologic specimens were available in five patients. Intratubular concentrically lamellated calcified bodies typical of TM were found in all cases (Fig. 3). No histologic evidence of inflammation or granulomatous disease was found.
Discussion Testicular microlithiasis is an uncommon and nonprogressive entity that is typically discovered as an incidental finding during investigation of unrelated testicular symptoms [5]. Three previous cases have been reported in the Englishlanguage sonographic literature [5-7], and a series of five patients (three with histologic proof) has been reported in the Spanish-language literature [8]. Nine cases of pathologically proved TM without sonographic examination have been reported [9-i 6], and one study of autopsy specimens found testicular intraluminal calcifications in 0.05% of boys [i i]. Histologic examination is probably more sensitive than sonography in detecting TM.
Downloaded from www.ajronline.org by SUNY Downstate Medical Center on 03/20/15 from IP address 138.5.159.110. Copyright ARRS. For personal use only; all rights reserved
AJR:i58,
TESTICULAR
May 1992
MICROLITHIASIS
1059
Fig. 2.-Longitudinal sonogram shows a hypoechoic region (arrow) representing seminoma. The remainder of the testis contains tiny hyperechoic foci typical of testicular microlithiasis.
Fig. 3.-Photomicrograph
of involved
testicle
shows concentrically lamellated calcific concretion (arrow) within Iumina of seminiferous tubules. (H and E stain, original magnification xlOO)
The sonographic appearance of TM is characteristic. Innumerable tiny bright foci, measuring less than 2 mm in diameter, are present diffusely throughout both testes. Acoustic shadowing is not seen, probably because of the small size of the calcifications. The hyperechoic foci correspond to the microcalcifications seen on testicular radiography and pathologic examination. There are no associated abnormalities in the epididymis or scrotal skin. Unilateral TM has not been described. The sonographic appearance of TM in our series is identical to that in previously reported cases [5-7, i 7], two of which describe the same patient [6, i 7]. Multiple hyperechoic regions may be seen on testicular sonography owing to calcified granulomas or focal scars; in these cases, the hyperechoic regions are larger and less numerous than those of TM [6]. Calcifications due to previous trauma or infection may be found in the epididymis or tunica vaginalis testis [4]. Solitary hyperechoic testicular masses can be caused by scar tissue, fibrosis, or benign adenomatoid tumors [3]. Hyperechoic regions can also be seen in the testicle as a result of orchitis [i], sarcoidosis [i8, i 9], or chronic infarction [i 9]; however, these hyperechoic regions are larger
and less well defined
than those
seen
in TM.
Solitary
hyperechoic regions greater than 5 mm in diameter have been described in nonviable primary testicular germ cell tumors [20], in intratesticular lipoma [2i], and in a benign fibrous intratesticular mass [4]. Recent reviews of the sonographic appearance of diffuse infiltrating testicular diseases do not describe a speckled appearance [22, 23]. The diffuse speckled appearance seen in TM has not been described in association with any other testicular abnormality. Histologic examination of the diffusely speckled testicle has invariably documented the presence of TM [5-9, i 7]. We believe
that
this speckled
sonographic
appearance
is specific
to TM, and therefore biopsy or excision in these cases is unnecessary. Testicular radiography may be useful to confirm the presence of intratesticular calcifications [9]. The hyperechoic foci seen on sonography represent calcifled concretions within the lumina of the seminiferous tubules
[5-7,
9-i
6, 24].
These
concretions
are formed
from
degen-
erating tubular epithelial cells, which slough into the tubule lumina. Lamellated concentric layers of collagenous material form within the tubule lumina, and this material serves as a site for dystrophic calcification [i 0]. Luminal obstruction can occur, and as many as 30-40% of the seminiferous tubules may be involved [iO]. TM is frequently associated with cryptorchidism or delayed testicular descent [5, 6, 9-i i J; however, the precise incidence of TM in this group is not known. Of the 23 cases reported in the English-language literature and in the present series, nine were associated with cryptorchidism or delayed descent of the testicle. TM has been found at histologic examination in two of 30 patients with cryptorchidism [i 0]. Associations have also been reported between TM and Klinefelter’s syndrome [i 2, i 3], male pseudohermaphroditism [i 2], Down’s syndrome [i 2], and pulmonary alveolar microlithiasis [i 4]. TM also has been associated with subfertility/mnfertility [8, is, 24]. Oligospermia or azoospermia has been documented in three patients [8]; the two subfertile patients in our series had normal semen analyses. The cause of subfertility in TM patients has not been clearly established. Subfertility and TM may both be sequelae of testicular maldescent. TM and testicular neoplasm can coexist. A case of malignant germ cell tumor [7] and two cases of seminoma in our series have been described in association with TM. The presence of TM did not impair sonographic diagnosis of the tumors. TM does not appear to be strongly associated with testicular neoplasm: none of the patients in our series developed clinically apparent testicular neoplasms during the follow-up period. However, this entity is associated with testicular maldescent and infertility, conditions that do carry an increased risk of testicular neoplasm. Since the risk of subsequent malignancy in testicular microlithiasis is unknown, clinical or sonographic surveillance of patients with TM may be prudent [7]. In summary, TM is an uncommon asymptomatic abnormality with a characteristic sonographic appearance. Patients’
Downloaded from www.ajronline.org by SUNY Downstate Medical Center on 03/20/15 from IP address 138.5.159.110. Copyright ARRS. For personal use only; all rights reserved
1060
JANZEN
symptoms should not be attributed to the presence of TM; unrelated abnormalities should be sought. This condition can be associated with genetic and urologic abnormalities. The finding of bilateral speckled testes on sonography establishes the diagnosis of TM; therefore, biopsy or excision in these cases is unnecessary.
ACKNOWLEDGMENTS We thank D. A. Stringer (British Columbia’s Children’s Hospital, B.C.), R. Pitman (Squamish General Hospital, Squamish, B.C.), and A. A. List (Auckland Public Hospital, Auckland, New Zealand) for providing cases. Vancouver,
REFERENCES 1 . Krone
KD,
Carroll
BA.
Scrotal
1985:23: 121 -1 39 2. Doherty FJ. (Jtrasound of the 1991;12: 131 -156 3. Vick CW, Bird KI Jr, Rosenfield
masses 4. 5. 6.
7.
with
a uniformly
ultrasound. nonacute
Radiol
scrotum.
Clin Semin
North
Am
US CT MR
AT, Viscomi GN, Taylor KJW. Scrotal hyperechoic pattern. Radiology 1983:148:
ET
AL.
AJR:158,
May 1992
8. MacKinnon J, Coz F, Diaz L. Testicular microlithiasis: echographic diagnosis of a new cause of orchialgia and infertility. Rev Chil Obstet Ginecol 1990:55:6-9 9. Weinberg AG, Currarino Pathol 1973:95:312-319 10. vegni-Talluri M, Bigliardi
G, Stone E, Vanni
IC Jr. Testicular MG, Tota
microlithiasis.
G. Testicular
Arch
microliths:
their
origin and structure. J Urol 1980:124: 105-i 11 ii . Nistal M, Paniagua A, Diez-Pardo JA. Testicular microlithiasis in two children with bilateral cryptorchidism. J Urol 1979:12i :535-538 i2. Bieger AC, Passarage E, McAdams AJ. Testicular intratubular bodies. J Clin Endocrinol Metab 1965:25: 1340-i 343 13. Lanman JT, Sklarkin BS, Cooper HL. Klinefelter’s syndrome in a ten month old mongolian idiot: report of a case with chromosomal analysis. N Eng! J Med 1960:263:887-892 1 4. Coetzee T. Pulmonary alveolar microlithiasis with involvement of the sympathetic nervous system and gonads. Thorax 1970;25:637-639 1 5. Schantz A, Milsten A. Testicular microlithiasis with sterility. Fertll Steril 1976:27:801-804 16. Priebe CJ Jr, Garret A. Testicular calcifications in a four year old boy. Pediatrics 1970:46:785-786 17. Mullins TL, Sant GA. Ucci AA, Doherty FJ. Testicular microlithiasis occurring in a post-orchiopexy testis. Urology 1986:27: i44-i47 i8. McAlister WH, Sisler CL. Scrotal sonography in infants and children. Curr Probl Diagn Radiol 1990:19:219-222 19. Blei L, Sihelnik 5, Bloom D, Stutzman A, Chiadis J. LJtrasonographic analysis of chronic intratesticular pathology. J Ultrasound Med 1983:2:
17-23
20.
209-211 Lipinski JK, Rao CA. Ljtrasound diagnosis of a benign calcified testicular mass: report of a case. J Can Assoc Radiol 1986:37: 1 1 2-i 13 Jaramillo D, Perez-Atayde A, Teele AL. Sonography of testicular microlithiasis. Urol Radiol 1989:11:SS-S9 Doherty FJ, Mullins TL, Sant GA, Drinkwater MA, Ucci AA. Testicular microlithiasis: a unique sonographic appearance. J Ultrasound Med 1987:6:389-391 Kragel PJ, Delvecchio D, Orlando A, Garvin DF. (Jtrasonographic finding
Shawker TH, Javadpour N, O’Leary T, Shapiro E, Krudy AG. Ultrasonic detection of “burned-out” primary testicular germ cell tumors in clinically normal testes. J Ultrasound Med 1983:2:277-279 21 . Hertzberg BS, Mahony BS, Bowie JD, Anderson EE. Sonography of an intratesticular liporna. J Ultrasound Med 1985:4:619-621 22. Subramanyan BA, Hon SC, Hilton S. Diffuse testicular disease: sonographic features and significance. AJR 1985:145: 1221 -1 224
of testicular microlithiasis
24.
Urology
1991:37:66-68
associated with intratubular
gem, cell neoplasia.
23. Aifkin MD, Kurtz AB, Pasto ME, et al. The sonographic and diffuse infiltrating Sasgawa I, Nakada
Testicular
diagnosis of focal
intrascrotal lesions. Urol Radiol 1984;6:20-26 T, Kazama T, Satomi 5, Katayama T, Matuda microlithiasis in male infertility. Urolint 1988:43:368-369
S.
