A 51-year-old man was referred at the urological department due to the primary suspicion of a left testicular cancer. Staging computed tomography of the thorax, abdomen, and pelvis was negative for lymphatic or hematogeneous metastatic tumor spread. Moreover, testicular tumor markers such as α-fetoprotein (AFP) and beta-human chorionic gonadotropin (β-hCG), and preoperative hormone levels (testosterone, LH, FSH) were within normal ranges.\nTesticular ultrasound confirmed a 0.9 × 0.9 × 1.0 cm rounded, peripheral, and hyperechoic lesion of the lower pole of the left testicle (Fig. a) connected with the tunica albuginea, without pathological signs of the right testicle. No exact vascular signs or vascular flow within this lesion were reproducible on baseline color and power Doppler sonography (Fig. b). Contrast-enhanced ultrasound (LOGIQ E9 ultrasound machine by GE Healthcare, Fairfield, Connecticut, USA) was performed as an additional diagnostic tool to clarify the vascularization of the suspicious lesion. Interestingly, the lesion was contrast-absorbing after bolus contrast agent application of 2.4 cc (SonoVue, Bracco, Milan, Italy), Fig. c. Moreover, real-time elastography (RTE) of the left testis was performed to evaluate the tissue elasticity of the tumor mass, showing a hard lesion (Fig. d). In summary, multiparametric ultrasound confirmed a vascularized and hardened lesion, therefore being suspicious of testicular cancer.\nNext, inguinal exploration with organ-sparing surgery and tumor enucleation was performed without ischemia. Intraoperative frozen section analysis of the tumor and tumor bed biopsies was performed, providing no evidence of malignant germ cell tumor or testicular intraepithelial neoplasia (TIN). Final pathology report confirmed a completely removed adenomatoid tumor of the left testicle arising from the tunica albuginea.
A 41 years old man referred to our department for painless enlargement in the left hemiscrotum. Personal and familial history were unremarkable, without epididymitis, torsion or trauma. On physical examination, a hard, painless, firm, intrascrotal mass at the lower pole of the left testis was revealed, apparently distinct from the testis and arising directly from the surface of the left epididymis. Scrotal skin epididymis, spermatic cord, inguinal region and right testis were normal.\nUltrasonography confirmed a solid isoechoic lesion lying on the border between epididymal tail and lower pole of the left testis, without any disruption of the architecture of the testical parenchyma. The testicular parenchyma immediately adjacent to the mass showed slightly degreased echogenity compared with the parenchyma elsewhere. Preoperative laboratory investigation, including hemogram, blood chemistry studies were within normal limits. Plasma levels of β-hCG (β-subunit human chronic gonadotropin), α-fetoprotein (AFP), lactic dehydrogenase (LDH) were within normal ranges. The first clinical impression was a probable germ cell neoplasm.\nThe patient subsequently underwent a total left orchiectomy-epididymectomy, which revealed a white, crescent-shaped, well circumscribed tumor, about 1,5 cm, without involvement of the testicular parenchyma.\nHistological appearance of this paratesticular tumor is represented by cuboidal cells, with vacuolated cytoplasm and with gaping spaces (Fig. ). The neoplasmatic cells had lymphoplasmacytic and eosinophilic infiltration, which varied in intensity, from scan to moderate dense, and especially the presence of prominent lymphoid aggregates, particularly towards the periphery of the neoplasm, is a helpful clue to the diagnosis of the adenomatoid tumor (Fig. ). The cellular vacuoles had a signet ring-like appearance in some fields but epithelial type mucin was not present There was no mitotic activity and no suspicious neoplasmatic areas in testicular parenchyma was been detected.\nImmunohistochemical positivity for mesothelial marker HMBE1 (mouse anti-human antigen mesothelial cell) and calretinin confirm the mesothelial origin of the tumor (Fig. , ). This tumor was diagnosed as an adenomatoid tumor in the epididymis and the patient underwent no additional treatment.