eMedicine Specialties > Pediatrics: Surgery > Urology

Prepubertal Testicular and Paratesticular Tumors: Differential Diagnoses & Workup

Author: Christopher S Cooper, MD, FACS, FAAP, Professor of Urology, Director of Pediatric Urology, University of Iowa, Children's Hospital of Iowa; Associate Dean for Student Affairs and Curriculum, University of Iowa Carver College of Medicine
Coauthor(s): Brian L Gallagher, MD, Resident Physician, Department of Urology, University of Iowa Hospitals and Clinics
Contributor Information and Disclosures

Updated: Sep 29, 2009

Differential Diagnoses

Hydrocele and Hernia in Children
Varicocele in Adolescents

Other Problems to Be Considered

Epididymitis
Testicular torsion

Workup

Laboratory Studies

  • Obtain a serum AFP level before treating a testicular mass.
    • AFP levels are elevated in 80% of patients with yolk-sac carcinomas and serve as a tumor marker.
    • The half-life of AFP is about 5 days, and levels should return to normal (<20 ng/mL) within 1 month after complete removal of the tumor.
    • AFP levels are usually elevated in neonates (approximately 50,000 ng/mL) and drop to 10,000 ng/mL by age 2 weeks and to 300 ng/mL by age 2 months; therefore, age-specific values should be used.
    • Persistently elevated AFP levels after surgery suggest tumor metastases or recurrence.
    • Liver dysfunction can also cause false-positive elevations of AFP levels.
  • Serum testosterone levels may be elevated in Leydig-cell tumors.
  • Gonadoblastoma may elevate levels of beta-HCG.

Imaging Studies

  • Ultrasonography is helpful in evaluating the testicle and in distinguishing an extratesticular mass from an intratesticular mass (see Media files 1-2).

    Ultrasonogram revealing cystic dysplasia of the t...

    Ultrasonogram revealing cystic dysplasia of the testicle.

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    Ultrasonogram revealing cystic dysplasia of the t...

    Ultrasonogram revealing cystic dysplasia of the testicle.


    Ultrasonogram in an infant revealing a heterogene...

    Ultrasonogram in an infant revealing a heterogeneous intratesticular mass that proved to be a juvenile granulosa-cell tumor.

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    Ultrasonogram in an infant revealing a heterogene...

    Ultrasonogram in an infant revealing a heterogeneous intratesticular mass that proved to be a juvenile granulosa-cell tumor.

  • Chest radiography should be performed, as 20% of yolk-sac tumors occur with metastases to the lung.
  • Patients with rhabdomyosarcomas require chest radiography, abdominal-pelvic CT scanning, bone scanning, and bone-marrow aspiration.

Procedures

  • The type of testicular tumor is diagnosed after inguinal orchiectomy or after an inguinal approach to testicular-sparing surgery is used.
  • When preoperative AFP levels are normal and the suspicion for a benign lesion (eg, cystic dysplasia, teratoma) is high, the tumor is excised from the testis with an inguinal approach. Intraoperative histologic confirmation of a benign lesion by frozen section permits testicular-sparing surgery.

Histologic Findings

Histologic evaluation of the yolk-sac tumor demonstrates eosinophilic periodic acid-Schiff (PAS)–positive inclusions in the cytoplasm of clear cells that consist of AFP and Schiller-Duval bodies. Teratomas and teratocarcinomas contain elements derived from more than one of the 3 germ tissues: endoderm, mesoderm, and ectoderm. These tumors are often cystic, and tissues such as skin, hair, bone, and even teeth may be present. Although they contain areas of poorly differentiated cells with a malignant appearance, teratomas are consistently benign in children younger than 2 years. About 90% of paratesticular rhabdomyosarcomas demonstrate a favorable embryonal pattern on histology.

Staging

The intergroup staging system for testicular germ cell tumors is as follows:

  • Stage I - Limited to the testis and completely resected (Eighty-five percent of children <4 y present with stage I disease, whereas only 35% of adults do.13 )
  • Stage II - Removed by transscrotal orchiectomy, involvement of scrotum or spermatic cord, persistently elevated markers
  • Stage III - Retroperitoneal lymph node involvement (≤2 cm, no visceral or extra-abdominal involvement)
  • Stage IV - Distant metastases

More on Prepubertal Testicular and Paratesticular Tumors

Overview: Prepubertal Testicular and Paratesticular Tumors
Differential Diagnoses & Workup: Prepubertal Testicular and Paratesticular Tumors
Treatment & Medication: Prepubertal Testicular and Paratesticular Tumors
Follow-up: Prepubertal Testicular and Paratesticular Tumors
Multimedia: Prepubertal Testicular and Paratesticular Tumors
References
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References

  1. Metcalfe PD, Farivar-Mohseni H, Farhat W, McLorie G, Khoury A, Bagli DJ. Pediatric testicular tumors: contemporary incidence and efficacy of testicular preserving surgery. J Urol. Dec 2003;170(6 Pt 1):2412-5; discussion 2415-6. [Medline].

  2. Cooper CS, Snyder HM III. Pediatric genitourinary cancer. In: Nachtsheim DA, ed. Urological Oncology. Georgetown, TX: Landes Bioscience; 2005.

  3. Ross JH, Kay R. Prepubertal testis tumors. Rev Urol. 2004;6(1):11-8. [Medline].

  4. Thomas JC, Ross JH, Kay R. Stromal testis tumors in children: a report from the prepubertal testis tumor registry. J Urol. Dec 2001;166(6):2338-40. [Medline].

  5. Agarwal PK, Palmer JS. Testicular and paratesticular neoplasms in prepubertal males. J Urol. Sep 2006;176(3):875-81. [Medline].

  6. Ross JH, Rybicki L, Kay R. Clinical behavior and a contemporary management algorithm for prepubertal testis tumors: a summary of the Prepubertal Testis Tumor Registry. J Urol. Oct 2002;168(4 Pt 2):1675-8; discussion 1678-9. [Medline].

  7. Pohl HG, Shukla AR, Metcalf PD, Cilento BG, Retik AB, Bagli DJ. Prepubertal testis tumors: actual prevalence rate of histological types. J Urol. Dec 2004;172(6 Pt 1):2370-2. [Medline].

  8. Shukla AR, Huff DS, Canning DA, Filmer RB, Snyder HM 3rd, Carpintieri D. Juvenile granulosa cell tumor of the testis:: contemporary clinical management and pathological diagnosis. J Urol. May 2004;171(5):1900-2. [Medline].

  9. Richie JP, Steele GS. Neoplasms of the testis. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA. eds. Campbell-Walsh Urology. 9th ed. Philadelphia: Saunders; 2007.

  10. Muller J, Ritzen EM, Ivarsson SA, Rajpert-De Meyts E, Norjavaara E, Skakkebaek NE. Management of males with 45,X/46,XY gonadal dysgenesis. Horm Res. 1999;52(1):11-4. [Medline].

  11. Wu HY, Snyder HM 3rd. Pediatric urologic oncology: bladder, prostate, testis. Urol Clin North Am. Aug 2004;31(3):619-27, xi. [Medline].

  12. Walsh TJ, Davies BJ, Croughan MS, Carroll PR, Turek PJ. Racial differences among boys with testicular germ cell tumors in the United States. J Urol. May 2008;179(5):1961-5. [Medline].

  13. Cushing B, Perlman EJ, Marina NM, Castleberry RP. Germ cell tumors. In: Pizzo PA, Poplack DG, eds. Principles and Practice of Pediatric Oncology. Philadelphia: Lippincott Williams & Wilkins; 2002.

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Further Reading

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Keywords

prepubertal testicular tumor, paratesticular tumor, cancer, neoplasms, yolk sac tumor, yolk-sac tumor teratoma, teratocarcinoma, seminoma, gonadal stromal tumor, juvenile granulosa cell tumor, juvenile granulosa-cell tumor, Leydig cell tumor, Leydig-cell tumor, Sertoli cell tumor, Sertoli-cell tumor, pediatric prepubertal testicular tumor, germ-cell tumor, embryonal carcinoma, teratoma, testis tumor, gynecomastia, congenital adrenal hyperplasia, gonadoblastoma, leukemia, lymphoma, rhabdomyosarcoma

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Contributor Information and Disclosures

Author

Christopher S Cooper, MD, FACS, FAAP, Professor of Urology, Director of Pediatric Urology, University of Iowa, Children's Hospital of Iowa; Associate Dean for Student Affairs and Curriculum, University of Iowa Carver College of Medicine
Christopher S Cooper, MD, FACS, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Urological Association, International Children's Continence Society, Phi Beta Kappa, Society for Basic Urologic Research, Society for Fetal Urology, and Society for Pediatric Urology
Disclosure: Nothing to disclose.

Coauthor(s)

Brian L Gallagher, MD, Resident Physician, Department of Urology, University of Iowa Hospitals and Clinics
Disclosure: Nothing to disclose.

Medical Editor

Bartley G Cilento, Jr, MD, Instructor, Department of Surgery, Division of Urology, Children's Hospital of Boston and Harvard Medical School
Bartley G Cilento, Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Harry P Koo, MD, Chairman of Urology Division and Director of Pediatric Urology, Virginia Commonwealth University; Professor of Surgery, VCU School of Medicine, Medical College of Virginia; Director of Urology, Children's Hospital of Richmond
Harry P Koo, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, and American Urological Association
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting

Chief Editor

Marc Cendron, MD, Associate Professor of Surgery, Harvard School of Medicine; Consulting Staff, Department of Urological Surgery, Children's Hospital Boston
Marc Cendron, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, European Society for Paediatric Urology, Johns Hopkins Medical and Surgical Association, New Hampshire Medical Society, Society for Fetal Urology, and Society for Pediatric Urology
Disclosure: Nothing to disclose.

 
 
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