Para Testicular Pseudotumeurs of Calcified Gait: A Case Report from the Nianankoro Fomba Segou Hospital (Mali) ()
1. Introduction
Para testicular tumor-like formations are rare and the literature reports that fibrous tumors of para testicular location are extremely rare benign tumors. Until 1992, only about twenty cases had been described [1]. The diagnosis of benignity, which allows conservative treatment, will be made intraoperatively in view of the macroscopic appearance with nodules that can be enucleated and confirmed by an extemporaneous examination [2]. Ultrasound shows that the nodule is extratesticular and therefore generally benign [3]. Testicular micro lithiasis is well described by previous studies but is of intra testicular location and of echographic discovery either by chance or in the context of associated pathologies, it remains the subject of controversy as to its prevalence and its link with these pathologies, and in particular with testicular cancer [4] [5]. Pseudotumors and epididymal tumors are also generally benign but well related to the epididymis, as well as albuginea cysts, sessile or pedunculated hydatid cysts of Morgagni and other masses formed at the expense of the testicular adnexa are attached to the testis. Paratesticular tumors are rare and complex tumors with insidious and poor symptomatology. The benign forms represent 70%. However, some paratesticular formations can be malignant such as paratesticular rhabdomyosarcoma which is a rare and aggressive tumor whose treatment is multimodal and involves surgery, chemotherapy and radiotherapy. Our objective was to discuss, from this observation and a review of the literature, the diagnostic and therapeutic aspects of these tumors in order to contribute to the improvement of the identification of these benign pseudotumors of para testicular localization.
2. Observation
This was a 25 year old patient who consulted for multiple masses next to the testicle with an increase in volume of the left hemi-scrotum that had been evolving for four years. The clinical examination revealed a good general condition and allowed to palpate two hard para testicular nodules, well circumscribed without infiltration of the skin in front. An ultrasound scan showed that the nodules were located at the expense of the epididymis in the form of rounded hyperechoic masses. Tumor marker assays (alpha-fetoprotein, chorionic beta-gonadotropin and lactate dehydrogenase) were normal.
The surgery allowed easy removal by digital cleavage of two granulomatous nodular masses of calcified appearance with regular contours, well rounded, smooth surfaces, hard consistencies, stony, without attachment to the testis but slightly adjoining the epididymis and the testicular vagina Figure 1, Figure 2. The largest one measured 2.5 cm Figure 3. The operation was completed by a resection of the testicular vagina.
The postoperative course was simple, the patient was reviewed at 3 months and then after 12 months without any sign of recurrence.
3. Discussion
Calcified pseudotumors are rare. From July 2013 to July 2021, i.e. in 8 years, we have recorded only one case, a patient with a healthy homolateral testicle and a healthy contralateral testicle. Fibrous tumors of testicular localization reported in the literature are extremely rare benign tumors. Calcifications are reported,
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Figure 1. Opening of the testicular vagina and evidence of pseudotumors.
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Figure 2. Removal of pseudotumors and verification of hemostasis of the pseudotumor bed.
often within the wall of the testicular vagina [6]. Testicular micro lithiasis has also been described by several authors, but it is intratesticular in location, small in size, and discovered incidentally on ultrasound or in the context of associated pathologies [4] [5]. We have recorded only one case of pseudotumors in 7 years. The extreme rarity of this pathology has been reported by other authors [7]. These para-testicular pseudotumors pose the problem of differential diagnosis with nodules of the epididymis, as these nodules may give rise to suspicion of urogenital tuberculosis, in particular epididymo-testicular tuberculosis, and may justify a search for Koch’s bacillus in the urine and a history of pulmonary tuberculosis or of another location in the patient [3]. In our case the patient had no particular history. However, he presented with a hydrocele tear which was leathered. Confusion may also occur with cord cysts, epididymal cysts, Morgagni’s hydatid cysts, and paratesticular lipoma. In this case, ultrasound examination is the cornerstone of the diagnosis [8].
Calcified pseudotumors have a hard, stony consistency. The diagnosis of benignity, which allows conservative treatment, will be made intraoperatively in view of the macroscopic appearance with nodules that can be enucleated and confirmed by extemporaneous examination [2]. In our patient the benign nature of these pseudotumours was suspected in view of the healthy appearance of the tissues adjacent to these nodules and their easy extirpability, as they had very few attachments to the epididymis and the vaginal tunic. However, it is also important to bear in mind the existence of para-testicular malignant tumours such as para-testicular rhabdomyosarcoma, which must be ruled out with the help of ultrasound, CT scan and the measurement of tumour markers [9].
As in our patient, the notion of hydrocele associated with a pseudotume was reported by Abdelhak [10].
4. Conclusion
Para testicular pseudotumors are rare and benign (1, 2, 6, 7), easy to diagnose, essentially clinical, and treated surgically by simple enucleation. However, the differential diagnosis is made with epididymal nodules, spermatic cord cysts, Morgagni hydatid cysts and albuginea cysts.