Jayapal Praveen,  Alharthi Omar,  Thakor Avnesh

Final Pr. ID: Poster #: CR-018

HISTORY AND CLINICAL COURSE:A 16-year-old male presented with worsening abdominal pain, non-bloody diarrhea, and unintentional weight loss. On exam, he had diffuse abdominal tenderness and unnoticed left testicular swelling. US demonstrated a heterogeneous left testicular mass; CT demonstrated a large heterogeneous left testicular mass with extensive tumor thrombus propagating along the left gonadal vein, into the renal vein, the IVC, right atrium, right ventricle with several metastatic pulmonary emboli. The patient underwent left orchiectomy, and pathology showed testicular mixed germ cell tumor with immature teratoma and yolk sac components. The patient was referred to our institution for further management of his intravascular and intracardiac tumor components, given the patient’s pathology fell under an intermediate category based on the “Intermediate Germ Cell Consensus classification” which supports treatment with curative intent given an 80% long-term survival rate.
PROCEDURE:An open surgical approach was used to remove tumor tissue from the right heart and supra-hepatic IVC. Percutaneous endovascular thrombectomy was then used to remove the tumor from the infra-hepatic IVC and the left renal vein 24 hours after the cardiac surgery.
Step 1: Distal Embolic Control: A single disc from an Inari Flow Triever device was deployed, via the right internal jugular vein, below the level of the hepatic veins to provide distal embolic control throughout the procedure. This is an alternative application for this device.
Step2: IVC tumor removal: An Inari Clot Triever device was deployed via the right common femoral vein. Multiple 360-degree sweeps throughout the IVC to ensure intravascular tumor removal as validated on follow-up IVC venography.
Step 3: Left renal vein tumor removal: The left renal vein thrombus was removed using a combination of the Flow Triever and aspiration catheter systems. IVUS and left renal venogram confirmed the tumor removal.
FOLLOW-UP:The hospital course was uneventful. The patient was anticoagulated with a tight INR goal of 1.5-2 to balance the need for anticoagulation and avoiding the risk of bleeding from recent cardiac surgery. Chemotherapy with Bleomycin, Cisplatin, and Etoposide was initiated upon discharge and will be reviewed by surgical oncology for retroperitoneal nodal clearance later. This case demonstrates the multi-disciplinary team approach to caring for a complex case of an extensive testicular tumor in a pediatric patient. Read More

Authors:  Jayapal Praveen , Alharthi Omar , Thakor Avnesh

Keywords:  Endovascular, thrombectomy, testicular tumor

Harvey Carly,  Allbery Sandra,  Powers Andria

Final Pr. ID: Poster #: CR-074

Juvenile Granulosa Cell Tumor of the Testis is a rare testicular tumor that falls within the category of stromal cord neoplasms. There have been less than 50 cases described in the literature with all cases being described as having a cystic component (1, 2). We present a case of a 6 month old boy presenting with unilateral scrotal swelling. Ultrasound evaluation revealed an entirely solid, hypervascular, intratesticular mass. Alpha-fetoprotein levels were negative. At surgery, radical orchiectomy was performed and pathology revealed a Juvenille Granulosa Cell Tumor.

Testicular tumors arising in the neonatal and prepubescent period are a unique set of tumors distinct from their adult counterparts. In this younger age group, germ cell tumors predominate. Of the germ cell tumors, Yolk Sac tumors are the main tumor of clinical significant, and the reason why alpha-fetoprotein is such a relevant marker (3). Stromal cell tumors account for only a small percentage of testicular tumors within this age group. When they do occur, Juvenile Granulosa Cell Tumors (JGC) predominate, particularly if the child is under 1 year of age, with this tumor type being the most common testicular tumor present at birth (3,4). JGC tumors are associated with genetic and structural anomalies of the Y chromosome, ambiguous genitalia, and contralateral undescended testis. One of their defining pathologic characteristics is positive staining with Inhibin (3).To date there are no cases of metastatic JGC tumors. In all reported cases, Sonographic evaluation demonstrates a grossly multicystic tumor (2). The adult variant of Granulosa Cell tumors can appear as a solid mass with little or no cystic component and carries the risk of metastasis of approximately 20% (2). Surgical management of testicular JGC tumors has largely been radical orchiectomy but, some studies have shown tumor sparing excision to be curative in cases with salvageable testicular parenchyma (2). This finding highlights the importance of including stromal cell tumors, particularly JGC, in the differential for solid appearing testicular masses in the neonate. With more reported cases of JGC tumors of the testes, surgical management could include a more conservative approach. Although JGC tumor of the testis is not known to be malignant, given the atypical features of this tumor and similarities with its more malignant adult counterpart, close surveillance is warranted to ensure benign course. Read More

Authors:  Harvey Carly , Allbery Sandra , Powers Andria

Keywords:  Juvenille Granulosa Cell Tumor, Testicular Tumor, Pediatric, Solid

Anum Syeda,  Wallace E. Christine

Final Pr. ID: Poster #: EDU-043

To describe the ultrasonographic appearances of the gubernaculum in boys, review its utility in diagnosing cryptorchidism and provide a functional illustration of the gubernaculum as it conducts the testis into the scrotum. We will elucidate this process with a review of the relevant embryology. Read More

Authors:  Anum Syeda , Wallace E. Christine

Keywords:  Gubernaculum, Testicular Descent, Cryptorchidism

Aboughalia Hassan,  Oztek Murat Alp,  Noda Sakura

Final Pr. ID: Poster #: EDU-008

A whirlpool describes rotating water created by opposing currents or upon an encounter with an obstacle. On imaging, it refers to a twist of the vascular pedicle of an organ, with a subsequent characteristic appearance on color Doppler images. Multiple abdominal pediatric emergencies are associated with a whirlpool sign, including midgut and other intestinal volvulus, testicular torsion, and ovarian torsion. This exhibit aims to review the underlying embryologic mechanism predisposing to this characteristic appearance, the role of this sign in the diagnosis of these conditions, the supporting imaging features that can help further define the diagnosis, as well as some pitfalls and differential diagnoses that can lead to a fallacious diagnosis. Read More

Authors:  Aboughalia Hassan , Oztek Murat Alp , Noda Sakura

Keywords:  Whirlpool sign, Midgut malrotation, Testicular torsion

Alves Timothy,  Gebarski Kathleen

Final Pr. ID: Poster #: EDU-044

While hydroceles, patent processus vaginalis, inguinal hernias, varicoceles, epididymitis, orchitis, torsion of testes and appendages are common in pediatric radiological practice, other pathology and anatomical variants are unusual and may not be included in every day practice. We composed a pictorial guide of a wide variety of variants and diseases for education and reference. Read More

Authors:  Alves Timothy , Gebarski Kathleen

Keywords:  scrotal, testicular, ultrasound

Chen Paula,  Marine Megan,  Misseri Rosalia,  Kaefer Martin,  Karmazyn Boaz

Final Pr. ID: Poster #: EDU-021

Testicular tumors in children often pose diagnostic challenges. There is a bimodal age distribution and the pathology encountered is age-related. The purpose of this exhibit is to familiarize pediatric radiologists with the types of testicular tumors, the different incidence of malignant tumors among age groups, as well as benign lesions with specific characteristics on ultrasound that do not require surgery.

In addition, we will discuss special situations related to specific syndromes such as Peutz-Jeghers and androgen insensitivity syndromes. We will discuss the role of imaging in guiding patient management.

1. Overview of pediatric testicular tumor types by age
a. Early childhood, pre-pubertal, pubertal
b. Incidence of malignant tumors in each age group

2. Imaging and lab workup of testicular tumors
a. US Imaging characteristics of various tumors
b. Potential role for contrast enhanced US
c. Lab workups
d. Indications for abdominal and pelvic CT scans
e. Follow up after tumor resection

3. Lesions with specific US characteristics that do not require surgery
a. Congenital Adrenal Rests
b. Rete testis
c. Intratesticular varicose veins

4. Management options
a. Radical orchiectomy
b. Testicular sparing/Enucleation
c. Follow-up

5. Special situations
a. Syndromes
b. Microlithiasis Read More

Authors:  Chen Paula , Marine Megan , Misseri Rosalia , Kaefer Martin , Karmazyn Boaz

Keywords:  Testicular tumors, Ultrasound

Willard Scott,  Birkemeier Krista

Final Pr. ID: Poster #: CR-029

We present the case of a 14 year old Asian male with a history of poorly controlled congenital adrenal hyperplasia (CAH) and growing testicular adrenal rest tumors. While on high dose steroid therapy, the lesions decreased in size from 1.1 x 1.0 cm to 0.5 x 0.8 cm. However, they subsequently increased in size, measuring 2 to 3 cm in length when the patient was not compliant with the steroid regimen due to Cushingoid side effects. The masses were bilateral, symmetric, and located at the mediastinum testis, all findings consistent with testicular adrenal rest tumors as opposed to Leydig tumor. With growth, they coalesced to form undulating masses with hyperechoic and hypoechoic layers mimicking the cerebrum, an appearance more typically seen in the adrenal glands at initial diagnosis of CAH. Current practice guidelines in much of the developed world typically result in early diagnosis and advanced therapy, making testicular adrenal rest tumors of this size and appearance unique. Read More

Authors:  Willard Scott , Birkemeier Krista

Keywords:  congenital adrenal hyperplasia, CAH, testicular adrenal rest tumor, TART

Sinayuk Boris,  Swenson David,  Herliczek Thaddeus,  Wallach Michael,  Cassese John

Final Pr. ID: Poster #: EDU-054

1. Highlight recent literature on ultrasound (US) imaging of the spermatic cord for testicular torsion.
2. Present illustrative cases of testicular torsion from our institution that demonstrate the spectrum of US findings, highlighting the importance of evaluating the spermatic cord and how relying solely on grayscale US and doppler of the testicle itself can be misleading in the setting of torsion.
3. Encourage real-time US evaluation of the spermatic cord in all suspected cases of testicular torsion. Read More

Authors:  Sinayuk Boris , Swenson David , Herliczek Thaddeus , Wallach Michael , Cassese John

Keywords:  testicular torsion, ultrasound, spermatic cord