Scrotal Lesions Research Articles

Bladder cancer that metastasized to the skin: A unique presentation that signifies poor prognosis.

In the United States in 2015, an estimated 74,000 new cases of bladder cancer were diagnosed and approximately 16,000 deaths were due to bladder cancer. We present a rare case of a patient with aggressive bladder cancer who presented with multiple inguinal and scrotal skin lesions that were proven to be metastatic urothelial malignancy. Bladder malignancy can involve the skin by direct tumor invasion, hematogenous routes, lymphatic spread, and direct seeding due to iatrogenic implantation. The cutaneous lesions have an extremely variable appearance, are resistant to therapies, and signify a dismal prognosis.

Remarkable Works and Cases in the History of Medical Mycology in Japan.

Several pathogenic fungi and cases related to Japanese medical mycologists were reviewed. Trichosporon inkin (as Sarcinomyces inkin) was reported as a pathogen of scrotal lesion by Oho in 1921, and Trichosporon asahii was isolated from generalized keratotic lesions in 1922 by Akagi in Japan. They were once included in Trichophyton beigelii, but then based on revision using DNA molecular technology, were returned to their original names.Microsporum ferrugineum was reported by Ota as a causative dermatophyte of tinea capitis in Japan and surrounding areas. It was once classified under the genus Trichophyton, but after the discovery of characteristic rough-walled macroconidia belonging to genus Microsporum, the fungus was again assigned to the original name.

Role of Ultrasound in Evaluation of Pediatric Scrotal Lesions

Role of Ultrasound in Evaluation of Pediatric Scrotal Lesions

Ultrasonography of the scrotum in adults.

Ultrasonography is the ideal noninvasive imaging modality for evaluation of scrotal abnormalities. It is capable of differentiating the most important etiologies of acute scrotal pain and swelling, including epididymitis and testicular torsion, and is the imaging modality of choice in acute scrotal trauma. In patients presenting with palpable abnormality or scrotal swelling, ultrasonography can detect, locate, and characterize both intratesticular and extratesticular masses and other abnormalities. A 12-17 MHz high frequency linear array transducer provides excellent anatomic detail of the testicles and surrounding structures. In addition, vascular perfusion can be easily assessed using color and spectral Doppler analysis. In most cases of scrotal disease, the combination of clinical history, physical examination, and information obtained with ultrasonography is sufficient for diagnostic decision-making. This review covers the normal scrotal anatomy as well as various testicular and scrotal lesions.

Gonadal Imaging in Endocrine Disorders.

Ultrasound (US) is the most widely available method of diagnostic imaging for the evaluation and characterization of gonadal lesions and is usually the method of choice because of its high accuracy, low cost and wide availability. Today's high-resolution images allow for a confident diagnosis of many scrotal and adnexal lesions, with high sensitivity and specificity. Magnetic resonance imaging (MRI) is reliable in the detection of gonadal lesions in males, allowing the differentiation into testicular or nontesticular lesions, and their characterization. It is also an accurate and cost-effective diagnostic adjunct in those patients with solid scrotal lesions for whom the findings of clinical and US evaluations are inconclusive. In females, MRI is recommended as a second-line investigation for the characterization of complex adnexal masses that are indeterminate on US. In this review, gonadal pathologies related with the steroidogenic and gametogenic function of the testes and ovaries will be discussed. The main imaging features of benign and malignant lesions will also be presented.

Routine hemoglobin electrophoresis for pediatric surgery day case in at-risk populations: Suggested algorithm for screening using clinical risk factors.

Hemoglobin electrophoresis (HBE) is a part of the preoperative routine requested by anesthetists. However, the prevalence of hemoglobinopathy in the population is low. This study aims to determine the clinical risk factors for hemoglobinopathies and propose clinical guidelines for preoperative screening of patients for pediatric day care surgery. A prospective study carried out over 12 months. Consecutive patients aged 6 months and older who had day case surgery were recruited to the study. Biodata and relevant clinical data were collated and documented in a proforma and analyzed using a statistical package for social sciences version 17. There were 124 patients106 boys and 18 girls. The median age was 3 years. Scrotal lesions were the most common conditions managed (71.7%). Seventy-eight percent of patients had HbAA, 15.3% had HbAS, and 4.8% had HbAC while 0.8% each had both HbSC and HbSS. At least one parent of 78.2% knew their Hb phenotype, of which, 79% were HbAA. A history of jaundice (P = 0.0001), hand and foot syndrome (P = 0.0001), frontal bossing (P = 0.0001), and low packed cell volume at surgery (P = 0.001) were found significant in predicting hemoglobinopathies. There was no mortality. Risk factors for hemoglobinopathies from this study included a positive history of jaundice, hand and foot syndrome, frontal bossing, and anemia. Proposed guidelines for HBE screening include the presence of hemoglobinopathy in one parent if one parent has sickle cell trait, and the other parent's genotype is unknown or if any of the risk factors is present.

Malignant Spermatic Cord Tumor as a Rare Scrotal Lesion: Case Report and Literature Review

Malignant Spermatic Cord Tumor as a Rare Scrotal Lesion: Case Report and Literature Review/strong> Malignant tumors of the spermatic cord are urologic rarities. Due to their rarity the therapeutic management is often inconsistent and characterized by individual clinical decisions. The treatment of choice is inguinal orchiectomy with extensive resection of the surrounding soft tissue. These neoplasms occur mostly in elderly patients. We report two patients who presented with scrotal masses and review what is currently known about this entity.

Rare Leiomyoma of the Tunica Dartos: A Case Report with Clinical Relevance for Malignant Transformation and HLRCC.

Background. Genital leiomyomas fall under the broader category of cutaneous leiomyomas, which are rare smooth muscle neoplasms accounting for 5% of all leiomyomas. Genital leiomyomas arising from the dartos muscle are exceedingly rare with fewer than 30 cases reported in the literature. They are typically benign and adequately treated with simple surgical excision; however, previously reported cases of malignant transformation and a possible link to the hereditary leiomyomatosis and renal cell cancer (HLRCC) syndrome warrant closer follow-up. Case Presentation. We report a case of a 47-year-old male refugee from Rwanda found to have a mobile, pea-sized, mildly painful scrotal lesion near the left penoscrotal junction and 1.5 cm indeterminate vascular mass in the right kidney. Surgical excision of the scrotal nodule was performed and the diagnosis of a dartoic leiomyoma was rendered. The presence of moderate nuclear atypia, rare mitotic activity, and close surgical margins prompted a wide reexcision. We report the surgical approach, pathologic findings, and clinical follow-up related to this scrotal lesion. Conclusion. Scrotal leiomyomas demonstrate a high rate of recurrence and pose a risk for malignant transformation. They may also indicate an underlying autosomal dominant syndrome associated with increased risk for development of an aggressive form of renal cell carcinoma. When discovered, management should include surgical excision, screening for syndromic features, and routine follow-up.

Application of Quasistatic Ultrasound Elastography for Examination of Scrotal Lesions.

The aims of this study were to investigate the value of applying quasistatic ultrasound elastography for examination of scrotal lesions, to investigate the features of normal testes on quasistatic elastography, and to establish whether testicular and epididymal lesions had specific quasistatic elastographic features. We screened 1073 patients who underwent color Doppler sonographic examinations of the testes and epididymides in our hospital and performed quasistatic elastography to evaluate their sonographic features. Measurement data were expressed as mean ± SD. For intergroup comparisons, we used paired t tests and independent-samples t tests, with P < .05 considered significant. Quasistatic elastography did not reveal any testicular or epididymal abnormalities in 625 cases. Seven cases showed testicular torsion; 3 cases showed testicular space-occupying lesions (1 case each of a testicular teratoma, testicular seminoma, and testicular endodermal sinus tumor); 176 cases showed epididymal lesions (138 cases of caudal epididymal inflammatory masses, 37 cases of caput epididymal cysts, and 1 case of an epididymal lymphangioma); and 262 cases showed varicocele. The normal testicular elastographic appearance showed a 3-ring structure: red surrounding bands with a blue edge region and a green central area. The stiffness in cases of testicular torsion, testicular space-occupying lesions, and epididymal lesions was increased, whereas caput epididymal cysts of different diameters appeared either as green, blue-green-red, or "scooped out." Elastographic results for patients with varicocele were not different from those for normal testes. Quasistatic elastography can reflect the relative stiffness of the testis and its surrounding tissues, thus providing a novel, reliable, convenient, and noninvasive method for clinical detection of testicular stiffness and related pathologic changes.

Scrotal imaging.

Pathological lesions within the scrotum are relatively rare in imaging except for ultrasonography. The diseases presented in the paper are usually found in men at the age of 15–45, i.e. men of reproductive age, and therefore they are worth attention. Scrotal ultrasound in infertile individuals should be conducted on a routine basis owing to the fact that pathological scrotal lesions are frequently detected in this population. Malignant testicular cancers are the most common neoplasms in men at the age of 20–40. Ultrasound imaging is the method of choice characterized by the sensitivity of nearly 100% in the differentiation between intratesticular and extratesticular lesions. In the case of doubtful lesions that are not classified for intra-operative verification, nuclear magnetic resonance is applied. Computed tomography, however, is performed to monitor the progression of a neoplastic disease, in pelvic trauma with scrotal injury as well as in rare cases of scrotal hernias involving the ureters or a fragment of the urinary bladder.

Pediatric andrology: the andrological patient from infancy to adulthood. Prevention interventions: how and when

Sonography, a non-invasive, quick method without biological impact on the gonad, has greatly improved the diagnostic possibilities; it is the gold standard for the male genital system (gonads and genito-urinary tract) and in fact has oriented the prevention interventions [1]. It recognizes almost 100% of scrotal lesions and their solid, liquid or complex nature. It has allowed to overcome the limits of traditional diagnostic methods for gonads like palpation, transillumination, and the Prader orchidometer for volumetric assessment. In fact, compared to this, sonography allows a more accurate volume measurement, expecially in small testicles; a correlation between measurements made with the orchidometer and those made with ultrasounds was found only for testicular volumes over 4 cc. [2]. Measurement of testicular volume is a fundamental element in pediatric andrology for evaluating puberty onset and progression. Furthermore, the sonographic exam is one of the best tools for assessing testicular pathologies like torsion, undescended testis, varicocele and in general in pathologies involving male genitalia; these cases can show significant variations of testicular volume. Testicular growth restriction may have relevant clinical implications for future testicular function [3]. The limits of traditional tools, like the orchidometer or the ruler for the measurement of pre-puberal testicle, are easy to identify: - The smallest pearl in Prader orchidometer is 1 ml, while sonography allows to make measurements in the first years of life (0,44 ml ± 0,03); - Orchidometer and ruler are known for overestimating testicular volume because they measure not only the didymus but also the epididymis (which in the first childhood is relatively big, compared to total testicular volume) and the scrotal tissues. Testicular volume is related to many reproductive endocrine parameters; therefore, a measurement of testicular volumes with a reliable method is appropriate, because any scrotal anomaly can influence testicular growth, and should be detected and treated as soon as possible. Moreover, andrological sonography is a first choice exam for male genitalia pediatric pathologies like acute scrotum, where diagnosis and clinical evaluations are particularly difficult. For example, during a suspected testicular torsion, a measurement made with a high resolution ultrasound machine by an expert examinator allows to reach a sensibility of 98% and a specificity of 99%, like scintigraphy and MRI with contrast medium. The sonographic study of the testicular region has absolute indications and relative indications. Absolute indications: difficult/inadequate objective clinical examination (sore and/or swelling testis, suggesting an acute scrotum; testicular torsion, trauma, undescended testis) or suspected testicular mass [4].

Chemical sterilisation of Bos indicus bull calves following intratesticular injection of zinc acetate: Effects on growth and concentrations of testosterone

The aim of this study was to determine the effects in Bos indicus calves of intra-testicular injection of either saline (n=9) or one of two doses of zinc acetate ((ZA1, 57.75mg, n=10, or ZA2, 71.75mg, n=10) or surgical castration (n=9) on circulating concentrations of testostosterone and liveweight. Human chorionic gonadotrophin (hCG, 1500IU) was administered 202 and 525 days after treatment on Day 0 and animals were slaughtered on Day 860. In animals left intact treatment with ZA reduced mean serum concentrations of testosterone (Saline: 5.58±0.79ng/mL, ZA1: 1.28±0.27ng/mL, ZA2: 1.01±0.17ng/mL; P<0.001) and concentrations 48h following administration of hCG. The maximum concentration of testosterone recorded throughout the study in six out of 19 animals treated with ZA was ≤0.21ng/mL. Treatment with ZA did not significantly affect live weights or carcass weights or result in any detectable scrotal lesions. Animals with concentrations of testosterone ≥1.0ng/mL exhibited greater liveweights throughout most of the study and yielded heavier carcass weights (340.9±7.02 versus 309.3±6.17kg, P=0.002). It is concluded that a single, intra-testicular administration of either 57.75mg or 71.75mg of ZA was able to similarly reduce circulating concentrations of testosterone without significantly affecting liveweights or carcass weights. Treatment with ZA can result in variation in circulating concentrations of testosterone which could lead to differences in behaviour, liveweights and carcass characteristics.

Cabozantinib-Getting Under the Skin of Cutaneous Toxicity.

Tyrosine kinases (TKs) are a family of proteins that play a key role in themost fundamental cellular processes including the cell cycle, proliferation, differentiation, cell death and survival and are crucial inoncogenesis. Tyrosinekinase inhibitors (TKIs) actby inhibiting the catalytic subunit of TKs. Clinical trials in several cancer types have established the role of these drugs in cancer therapeutics. Although TKIs are “targeted therapeutics,”many inhibit a range of kinase receptorswithvariedpotencyand selectivity. Targeted receptors include vascular endothelial growth factor receptor (VEGFR), platelet-derivedgrowthfactor receptors (PDGFRs), fibroblastgrowth factor receptor (FGFR), epidermal growth factor receptor (EGFR), c-KIT, FLT-3, c-MET, MEK, BRAF, and insulin-like growth factor receptor (IGFR).1 Tyrosinekinase inhibitors causeaspectrumofdermatologic adverse events that has been described as a “class effect.” These adverse effects include rash, hand-foot-skin reaction (HFSR), alopecia, depigmentation, pruritus, xerosis, acneiform rashes, scrotal lesions, andmucositis. The distinctmultikinase inhibition profile of TKIs produces a different constellation of these cutaneous adverse events (CEs).2 Despite this spectrum,many phase 3 trials involving TKIs reportedCEscollectivelyas “skin toxicity.”There isclearlyaneed forgreaterdetail anddescriptionsof therangeofCEsrelatedtothese agents. In support of this, one meta-analysis2 focusing on CEs reportedonlyonHFSR, andpruritus. Toelucidate the full potential diversity of CEs, 2 small prospective trials3,4 with sorafenib and sunitinib, respectively, were designed. Zuo et al report the incidence of CEs in patients treated with cabozantinib administered at a dose of 60 mg/d continuously in metastatic urothelial carcinomabymeans of dedicated history and physical examination.Adermatologist reviewedpatientsonlywhen signs and symptoms of skin toxicity were present. Cabozantinib is a potent, small-molecule, oral multi-TKI targeting VEGFR2, c-MET, RET, c-KIT, AXL, and FLT3. In 2012, the US Food andDrug Administrationapprovedcabozantinib for the treatmentofmetastaticmedJAMADERMATOLOGY

Primary Paratesticular Mucinous “Ovarian-Type” Adenocarcinoma: A Rare Case of Scrotal Tumor in a Patient With History of Bilateral Cryptorchidism

Ovarian-type epithelial tumors are extremely rare in testis and paratestis, and in literature no cases of this tumor are reported in a patient with history of bilateral cryptorchidism. We describe a case of an 81-year-old man with a scrotal ulcerative lesion associated with signs of infection. After a skin biopsy showing tumor cells and mucin, we performed a surgical resection of this scrotal lesion and the final pathologic examination revealed a mucinous adenocarcinoma with medium grade of differentiation. The pathologist suggested performing additional tests of this tumor to differentiate it from mucinous “ovarian-type” paratesticular tumor and from a metastatic tumor. We did not find any tumor of different type. We discuss clinical presentation, differential diagnosis and treatment of this rare tumor. World J Nephrol Urol. 2015;4(4):260-263 doi: http://dx.doi.org/10.14740/wjnu235w

Advantage of Adding Diffusion Weighted Imaging to Routine MRI Examinations in the Diagnostics of Scrotal Lesions.

SummaryBackgroundThe purpose of the study is to identify the diagnostic value of adding diffusion weighted images (DWI) to routine MRI examinations of the scrotum.Material/MethodsThe study included 100 testes of 50 patients with a unilateral testicular disease. Fifty normal contralateral testes were used as a control group. All patients underwent conventional MRI and DWI examinations of the scrotum. The results of MRI and DWI of the group of patients treated surgically were correlated with histopathological findings. The MRI and DWI results of non-surgical cases were correlated with the results of clinical, laboratory and other imaging studies. Comparison of the ADC value of normal and pathological tissues was carried out followed by a statistical analysis.ResultsThere was a significant difference between ADC values of malignant testicular lesions and normal testicular tissues as well as benign testicular lesions (P=0.000). At a cut-off ADC value of ≤0.99, it had a sensitivity of 93.3%, specificity of 90%, positive predictive value of 87.5%, and negative predictive value of 94.7% in the characterization of intratesticular masses.ConclusionsInclusion of DWI to routine MRI has a substantial value in improving diagnosis in patients with scrotal lesions and consequently can reduce unnecessary radical surgical procedures in these patients.

Lesions and Neoplasms of the Scrotum and its Contents: A Review

Lesions and Neoplasms of the Scrotum and its Contents: A Review Reviews of the scope of scrotal and testicular lesions and neoplasms that may present are presented to assist in developing a differential diagnosis if a patient with such a lesion is encountered. A familiarity will assist with recognition, as well as when consultation is needed.

A Case of Extramammary Paget's Disease Resistant to Photodynamic Therapy and Surgery Successfully Treated with Radiotherapy.

Dear Editor: Although surgery is widely accepted as the first-line treatment for extramammary Paget's disease (EMPD), it cannot always be accomplished due to its frequent involvement of areas with important function1. Nonsurgical treatments including radiotherapy (RTx) and photodynamic therapy (PDT) are considered in such cases. We report a case of EMPD refractory to PDT and surgery that was successfully treated with RTx. A 68-year-old man presented with a well-defined erythematous patch with ulceration on the left side of scrotum, which enlarged during the last 7 months (Fig. 1A). Skin biopsy revealed numerous Paget cells (Fig. 2). Possible accompanying internal neoplasms were discounted through multiple means, ranging from physical examination to positron emission tomography/computed tomography. Diagnosed as localized EMPD, the patient was primarily treated with PDT because he strongly requested preservation of his genitourinary functions. Methyl aminolevulinate cream (Metvix; Galderma, Fortworth, TX, USA) was applied occlusively and was maintained for 3 h. The lesion was then irradiated with a 630-nm light-emitting diode (Aktilite CL128; Photocure, Oslo, Norway). After two sessions, the patient showed a partial response and underwent local excision. He was treated with 15 sessions of PDT for possible remnants. As Paget cells were still seen on follow-up biopsy of the surgical margin, he underwent a three-stage Mohs surgery and received 11 additional sessions of PDT. Nonetheless, the lesion persisted clinically. We referred him to the radiation-oncology clinic. Radiation was administered by using an electron beam of 6 MeV, at 200~250 cGy per day, 4 days a week, until a total dose of 37 Gy was reached. He received subsequent RTx with a total dose of 30 Gy in same manner. The lesion disappeared completely. After 18 months, the patient revisited our clinic with an erythematous patch on the scrotum (Fig. 1B). Biopsy only revealed telangiectatic dermal vessels. Fig. 1 (A) Patient image at initial visit. (B) The patient revisited our clinic suspecting of recurrence. The biopsy of skin lesion did not show any tumor cells. Fig. 2 Skin biopsy showing acanthotic epidermis with numerous Paget cells of large nucleus and eosinophilic cytoplasm (H&E, ×200). A systematic review of clinical studies examining the use of PDT for EMPD showed that of 133 EMPD lesions, 77 exhibited complete response and 52 exhibited partial response with satisfactory cosmetic outcome in all patients2. However, the durability of this response remains unclear, as the follow-up periods were typically less than a year2. In a long-term follow-up study of EMPD in situ for 24 months, the recurrence rate was 50%. The authors stated that PDT should be recommended only for cases of scrotal lesions <4 cm in diameter3. Larger lesions showed an unfavorable response presumably because of the denser infiltration of Paget cells and more adnexal involvement, followed by disproportionate protoporphyrin IX accumulation in the glands resulting in photodynamic oxygen depletion. In the present case, the lesion was much larger than 4 cm, which may have been responsible for the ineffectiveness of PDT. The optimal RTx dose is not standardized; however, a total of 40~50 Gy has been considered suitable for primary treatment4. The lesion of our case was refractory to other therapies; hence, a higher dose of 67 Gy was chosen. In conclusion, EMPD lesions resistant to PDT and surgery may be significantly resolved with RTx; thus, it should be considered a treatment option in cases of repeatedly unsuccessful PDT and surgery.

Pattern of scrotal examination by physicians in the Eastern Province of Saudi Arabia

Introduction: A wide variety of pathological lesions affect the scrotal contents. They include both benign and malignant lesions. Missed or delayed diagnosis of such lesions can lead to compromised fertility, cosmetic deformities, testicular loss or even death. Early diagnosis of scrotal lesions can prevent the possible development of such complications. Objectives: The pattern of scrotal examination by physicians in the Eastern Province of Saudi Arabia was evaluated in this study to assess the extent of efficacy for early diagnosis. Materials and methods: In this cross-sectional study of scrotal pathology, self-administered questionnaires regarding scrotal evaluation were answered by physicians of different disciplines, including emergency care, internal medicine, paediatric surgery, family medicine and general practitioners. The questionnaires included direct questions on clinical examination of the scrotum as well as clinical scenario quizzes. Collected data were analysed with SPSS (Statistical Product and Service Solutions) version 17 (SPSS Inc., Chicago, IL, USA). The chi-squared test was used to analysis categorical variables, while the t -test was used for continuous variables. Factors affecting scrotal evaluation were assessed by logistic regression. Results: 257 questionnaires were analysed. Routine evaluation of the scrotum was performed by only 14% of respondents. Among the physicians who did not perform routine scrotal examination, 64.2% restricted it to cases with scrotal complaints and 16% considered the conservative cultural nature of their patients a hindering factor. Forty-five per cent did not perform scrotal examination in the standing position. Only 27.8% advised patients with high risk of testicular cancer to perform routine self-examination of their testicles. Conclusions: This study revealed a significant deficiency of early detection of scrotal disease by physicians in the Eastern Province of Saudi Arabia with a high probability of development of complications. We recommend that all physicians be advised to follow a well-structured protocol for scrotal examination during routine practice.

Primary apocrine adenocarcinoma of scrotum suspected as urothelial carcinoma metastasis: A clinical and pathological dilemma

A 78-year-old man presented with an enlarging, tender mass in the scrotum separate to the testes. This was on the background of radical cystoprostatectomy, urethrectomy, and ileal conduit formation for high-grade urothelial carcinoma of the bladder invading submucosa 3 years prior. Examination revealed a 4 × 5 cm lesion, which was hard, fixed to the overlying skin and nodular to palpation. Ultrasound confirmed a solid mass in the scrotum extending into the perineum. Computerized tomography of the chest, abdomen, and pelvis revealed enlargement of inguinal lymph nodes but no other metastases. Complete resection of the scrotal lesion and selective removal of regional lymph nodes was performed. Rather than a cutaneous scrotal metastasis from the bladder urothelial carcinoma, histological examination suggested a primary apocrine adenocarcinoma of the scrotum. This case report explores the clinical and pathological features associated with both of these unusual differential diagnoses.

Scrotal Skin Metastases of Renal Cell Carcinoma: A Case Report

Cutaneous metastasis from renal cell carcinoma is believed to be rare. We present a 66-year-old man operated for kidney cancer 20 years ago and has consulted for a scrotal lesion that had started 20 days. The physical examination revealed an erythematous lesion. A biopsy of the scrotal skin was made. We found a scrotal metastasis of renal cell carcinoma.