Dr Matthew Seager amp Dr Miles Walkden BSGARBSUR Interesting Cases 2019 m atthewseager1nhsnet Clinical information 25 male 2 week referral by GP due to 34 cm lump superior to the left testicle ID: 930265
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Slide1
A case that left us wondering...
Dr Matthew Seager & Dr Miles WalkdenBSGAR-BSUR Interesting Cases 2019matthew.seager1@nhs.net
Slide2Clinical information25 male
2 week referral by GP due to “3-4 cm” lump superior to the left testicleFelt to be epididymal cyst, but could be testicular in origin O/E
Slide3Longitudinal section ultrasound image - left paratesticular region. * - epididymis thought to be separate.
*
Slide4Longitudinal section ultrasound image - left paratesticular region with colour Doppler
Slide5Transverse section ultrasound image
– left paratesticular region with colour Doppler
Slide6Differential diagnosis
Epididymal cyst Solid paratesticular lesions:
Adenomatoid tumour
Spermatic cord lipoma
Leiomyoma
Haemangioma
Sarcoma
MDT decision: given vascularity -> surgical biopsy +/- excision
✗
- not cystic
? -
extremely rare, but is vascular
?
- usually epididymal - tail
?
-
long history of lump
?
-
atypical appearance
?
-
not typically so vascular
Slide7Final diagnosisLesion separate from epididymis at surgery
Closely associated with testicular vessels so not removed3 x biopsies obtained:Ectopic splenic tissueGiven the location - final diagnosis of splenogonadal fusion
Slide8White pulp
Red pulp
Slide9Discussion
Splenogonadal fusion:M:F 15:1, nearly all leftClose proximity of developing gonad and spleen in embryonic weeks 5-8Continuous or discontinuousContinuous variety – 1/3 congenital abnormalities e.g. cryptorchidism, limb defects
Fusion with mesonephric derivatives rarely
Slide10Discussion
Presentation40% scrotal swelling20% inguinal hernia18% autopsy diagnosis15% cryptorchidism7% other
ImagingSlight reduced reflectivity relative to testisMay be difficult to separate from testis
–
DD for testicular Ca
Central vascular pattern branching to periphery c.f. disorganised malignant
Difficult to pre-operatively suspect but
99m
Tc sulphur colloid diagnostic
Varma et al.
Marko et al.
Slide11Discussion
Longitudinal section ultrasound image
Slide12Discussion
ManagementAvoid unnecessary orchidectomy!No evidence increased malignancy
✗
Slide13Key learning points
Rare conditionConsider splenogonadal fusion with a paratesticular mass and congenital anomaliesAwareness may allow appropriate pre-operative workup to avoid orchidectomyImportant to be aware of more common causes for solid paratesticular lesions
Slide14References
Putschar WGJ, Manion WC. Splenic-gonadal fusion. Am J Pathol. 1956;32: 15–33. Carragher AM. One hundred years of splenogonadal fusion. Urology.
1990;35: 471–75. Varma et al.
Sonographic
and CT features of splenogonadal fusion.
Pediatr
Radiol
. 2007;37(9): 916-9.
Marko et al. Testicular seminoma and its mimics.
Radiographics
. 2017;37(4): 1085-98.
Stewart VR,
et al.
Splenogonadal fusion. B-mode and color Doppler sonographic appearances. J Ultrasound Med. 2004;23: 1087-90.