Review article
Benign scrotal masses in children – some new lessons learned

https://doi.org/10.1016/j.jpedsurg.2016.07.016Get rights and content

Abstract

Introduction

A preponderance of benign intratesticular masses in pre-pubertal males encourages testicular-sparing surgery (TSS).

Objective

To review outcome of benign testicular lumps in children managed at a tertiary pediatric center more than 7.5 years.

Methods

A retrospective review of pediatric benign testicular lesions from January 2008 to June 2015 was performed.

Results

There were twelve benign intratesticular tumors. Of these, 11 were in pre-pubertal males; comprising four teratomas, two epidermoid cysts, one dermoid cyst, two cases of Leydig cell hyperplasia, one cystic dysplasia of the rete testis and one large simple intratesticular cyst. We illustrate a case of Leydig cell hyperplasia presenting with precocious puberty limited to the ipsilateral hemi-scrotum. TSS was attempted in all 11 pre-pubertal cases, but successfully performed in seven. TSS was possible for a large testicular cyst seemingly replacing the entire testis, with evidence that the testis reconstituted itself after surgery. Recurrence of an epidermoid cysts reported.

Conclusion

For the first time in the literature, this series reports Leydig cell hyperplasia presenting with ipsilateral hemi-scrotal changes of precocious puberty; shows evidence that the testis reconstitutes itself after TSS for a large cyst; and reports recurrence of an epidermoid cyst after TSS.

Section snippets

Methods

A retrospective review was undertaken of all pediatric patients at this institution undergoing surgical excision of intrascrotal masses between January 2008 and June 2015. Cases were identified from both the theater database and the histopathology database. Malignant testicular and paratesticular tumors and tumors in patients with disorders of sex development were excluded from further review. Medical records of cases with benign intratesticular masses were reviewed to determine demographics,

Results

Twenty-one children underwent surgery for excision of intrascrotal masses, eighteen of whom were pre-pubertal males. Nine of the twenty-one had malignant intrascrotal masses. Seven malignancies occurred in the pre-pubertal age group, four of which were malignant yolk-cell tumors, all with elevated serum AFP. The other three were paratesticular rhabdomyosarcoma. All cases with clinical features of malignancy underwent up-front radical orchidectomy. The two malignancies in the post-pubertal age

Discussion

There is increasing evidence that pre-pubertal testicular tumors are a distinct entity from tumors occurring in the adult testis [3]. Benign testicular tumors occur more commonly than malignant tumors in the pre-pubertal population, and consideration should thus be given to TSS [3], [4], [6]. Pre-pubertal testicular malignancy treated with orchidectomy has a good prognosis with survival rates of 99% at 5 years [1], [6]. Radical orchidectomy for the more common benign tumors results in organ loss

Teratoma

Four of the 11 benign pre-pubertal cases were testicular teratoma. Teratoma accounts for 45–50% of childhood testicular tumors in studies [4], [5], [10], [11]. It usually presents at the median age of 13 months (range 0–18 months) [1]. Teratomas are mostly benign in pre-pubertal males but often harbor malignancy post-pubertally [12], [13], [14]. On ultrasound they often have a heterogenous appearance with areas of calcification [1]. Histology is often pure with diploid DNA content containing all

Conclusion

Unlike post-pubertal lesions, a large proportion of pre-pubertal lesions are benign. The most common lesions were benign teratoma followed by epidermoid and dermoid cysts. Rare cases included cystic dysplasia of the rete testis, Leydig cell hyperplasia and large simple testicular cyst. To our knowledge, this series is the first to report recurrence of a benign epidermoid cyst. It is also the first to demonstrate signs of precocious puberty limited to the ipsilateral hemiscrotum in a child with

Conflict of interest

The authors all agree that they have no financial and personal relationships with other people or organizations that could inappropriately influence (bias) their work. This study has no sponsors or funding source.

Ethical approval

I have read the policy of the journal on ethical consent and this work has institutional approval: GEKO number 5422.

Acknowledgement

We would like to acknowledge the work of Dr. Amanda Ireland and Dr. David Paton, pathologists at Princess Margaret Hospital who provided histopathology imaging and descriptions. Furthermore, the work of Dr. Ronald Cohen, urolopathology consultant, who provided further clarification and information on pathology of testicular tumors.

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