Benign infantile hemangioma presenting as solid testicular ... › fallcongress › multimedia ›...
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Victor Kucherov1, Kudakwashe Chikwava2, Steven Blumer2, T. Ernesto Figueroa2
1. Thomas Jefferson University Hospital, Philadelphia, PA
2. Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
Benign infantile hemangioma
presenting as solid testicular mass
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History of present illness
3-month old boy presented with right scrotal
swelling, concern for right hydrocele
Examination: enlarged and firm right testicle
concerning for solid mass
Exam otherwise benign without signs of
lymphadenopathy or intra-abdominal mass.
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History of present illness
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Laboratory and imaging evaluation
Scrotal ultrasound: 4 cm exophytic right testicular mass with extenstion into spermatic cord with satellite lesions in right testicle
Serum tumor markers: within normal limits (AFP and hCG)
CT scan of the chest, abdomen, and pelvis: no metastatic disease
Overall concern for malignant process
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Laboratory and imaging evaluation
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Management
Parents counseled for child to undergo right radical orchiectomy
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Pathology
Grossly the specimen was a pink/lobulated mass displacing the testicle inferiorly
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Pathology
Microscopically mass appeared to be arising from tunica albuginea and visceral tunica vaginalis with focal extension into distal spermatic cord and testicular parenchyma noted
Cells formed numerous capillary beds
Immunohistochemistry staining was negative for germ cell and sex-cord stromal markers (AFP PLAP, cytokeratin 7 and AE1/AE3, CD30, CD117, inhibin), positive for CD31 and GLUT-1
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Pathology
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Pathology
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Final diagnosis
Benign infantile hemangioma
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Testicular infantile hemangioma
Rare, benign vascular neoplasm
Subtypes Cavernous Capillary Cellular capillary Epithelioid Juvenile
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Testicular infantile hemangioma
No well established pre-disposing risk factor
Infant presentation of testicular hemangioma especially rare
Two major case series: Kryvenko et al. (2013) and Hugar et al. (2018)
18 cases reviewed between 1992 - 2013 2 of 18 cases in age < 1 year Essentially all treated with radical
orchiectomyKryvenko O, Epstein J. Testicular hemangioma: a series of 8 cases. Am J Surg Pathol. 2013;37:860-866.
Hugar SB et al. Pediatric Testicular Hemangioma in a 10-Year-old: A Rare Entity That May Mimic Malignancy With Appraisal of the Literature. Urology.
2018 Apr;114:175-180.
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Testicular infantile hemangioma
Scrotal US: echogenic, hypervascular lesion
Markers: negative AFP/hCG
Pathology: variable immunohistochemicalanalysis, typically CD31 positive (vascular endothelial marker)
May invade Misdiagnosis possible: angiosarcoma,
Leydig cell tumor, regressed germ cell tumor
Kryvenko O, Epstein J. Testicular hemangioma: a series of 8 cases. Am J Surg Pathol. 2013;37:860-866.
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Testicular infantile hemangioma
Natural history: spontaneous involution
Management Typically radical orchiectomy given
concern for underlying malignancy Partial orchiectomy if technically feasible
No formal guidelines for follow-up; no known association with hemangiomas at other sites
Kryvenko O, Epstein J. Testicular hemangioma: a series of 8 cases. Am J Surg Pathol. 2013;37:860-866.
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Testicular infantile hemangioma
Contrast-enhanced US (CEUS)/strain elastography may be useful in diagnosis
Bernardo et al.: testicular hemangioma in 66 M Early/avid uptake of contrast on CEUS Strain elastography consistent with soft
tissue mass (similar pattern to liver/spleen hemangioma)
No reported use in testicular infantile hemangioma
Bernardo S, et al. Multiparametric sonographic imaging of a capillary hemangioma of the testis: appearances on gray-scale, color Doppler, contrast-
enhanced ultrasound and strain elastography. J Ultrasound. 2015 Nov 27;19(1):35-9
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Summary
Infantile testicular hemangioma: rare testicular neoplasm
Benign lesion that may invade testicle/cord
Difficult to differentiate from malignancy on imaging; CEUS may be useful
Treatment: enucleation if possible; intra-operative frozen section may be helpful for clinically equivocal cases with experienced genitourinary pathologists
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Thank you