Case Report

Unilateral Testicular MicrolithiasisAssociated with a Seminoma

Thomas G. Vrachliotis, MD, David E. Neal, MD

Department of Radiology, Ohio State University Medical Center, 450 West 10th Avenue, Rhodes Hall,Columbus, Ohio 43210

Received 8 May 1997; accepted 27 May 1997

ABSTRACT: Unilateral testicular microlithiasis is anuncommon entity that is important because of its as-sociation with malignancy. We describe a case inwhich the initial clinical presentation was that of meta-static cervical lymphadenopathy. Subsequent sono-graphic examination of the testes revealed right tes-ticular microlithiasis and a small, hypoechoic, ill-definedmass, which proved to be a seminoma. Since testicularmicrolithiasis is highly associated with testicular malig-nancy, it cannot be considered a benign condition.Sonographic follow-up examinations are warranted inpatients with testicular microlithiasis to detect thepossible development of malignancy. © 1997 JohnWiley & Sons, Inc. J Clin Ultrasound 25:505–507, 1997.

Keywords: microlithiasis; ultrasonography; semi-noma

Testicular microlithiasis is an uncommon en-tity that is usually discovered incidentally

during sonography of the scrotum. Although thesonographic appearance of testicular microlithia-sis is typical enough to render biopsy unneces-sary, there appears to be a frequent association ofthis condition with testicular malignancy.1 Thisassociation should prompt subsequent follow-upexaminations.2,3 We describe a case of unilateraltesticular microlithiasis associated with a smallseminoma, which presented initially as meta-static cervical lymphadenopathy.

CASE REPORT

A 27-year-old white man presented for evaluationof a mass in the left posterior lower neck. Sonog-raphy revealed multiple hypoechoic lymph nodes

ranging in size from 0.2 to 2.5 cm in the left pos-terior neck triangle. A computed tomogram of theneck confirmed the sonographic findings. Chestand abdominal contrast-enhanced computed to-mography did not demonstrate intrathoracic orintra-abdominal metastatic disease. Biopsy of thecervical nodes revealed seminomatous carcinoma.

Scrotal sonography was subsequently per-formed using a commercially available ultra-sound scanner (Acuson 128 XP-10, MountainView, CA) with a 7.0-MHz linear-array trans-ducer. The right testis measured 4.9 × 3.0 × 1.7cm and showed innumerable punctate echogenicfoci without shadowing, consistent with testicularmicrolithiasis (Figure 1). A hypoechoic mass mea-suring 2.5 × 1.3 × 1.0 cm with ill-defined borderswas identified in the medial posterior aspect of theright testis (Figure 2). No flow was detected in thismass with conventional or power Doppler imaging.The right epididymis had a normal appearance. Theleft testis measured 5.2 × 2.7 × 1.9 cm and showedno evidence of echogenic foci or of an intratesticularmass. The left epididymis was unremarkable ex-cept for a 0.3-cm cyst in the epididymal head.

Right orchiectomy was performed, and patho-logic examination of the resected testis revealedthat the tumor was of seminomatous origin andwas histologically identical to specimens from thecervical lymph nodes. Furthermore, many of theseminiferous tubules showed a thickened, hyalin-ized basement membrane and incomplete sper-matogenesis, suggesting that the right testis mayhave been a cryptorchid testis. The patient had anuneventful immediate postoperative course.

DISCUSSION

Testicular microlithiasis is an uncommon andnonprogressive entity that is usually discovered

Correspondence to: T.G. Vrachliotis, Room S255

© 1997 John Wiley & Sons, Inc. CCC 0091-2751/97/090505-03

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incidentally during sonography for scrotal symp-toms.4 Its prevalence is 0.05–0.60%,2 and morethan 80 cases have been documented by pathol-ogy or sonography.5 Histologically, testicular mi-crolithiasis consists of concretions within theseminiferous tubules.6 Electron microscopy find-ings suggest that the etiology is related to break-age of the basement membrane and precipitationof a glucoprotein matrix from which the microcal-cifications are formed.5 The calcium is present asa result of failure of Sertoli’s cells to phagocytosedegenerating cells within the tubules.7

The sonographic pattern of testicular microli-thiasis is characteristic and was first described byDoherty et al8 as ‘‘innumerable tiny bright echoesdiffusely and uniformly scattered throughouttheir substances.’’ Although the sonographic ap-pearance of testicular microlithiasis is specificenough to render biopsy unnecessary, the distri-bution of the microcalcifications may show con-siderable variation; the number of echogenic focimay vary from the left to the right testis, and aperipheral rather than diffuse pattern may oc-cur.1

Unilateral testicular microlithiasis is ex-tremely rare. One case was reported as part ofBackus et al’s series,1 but no further descriptionor disease association was given. Recently, Win-ter et al9 described the development of mixed em-bryonal carcinoma and seminoma in a patientwho 3 years earlier had had a normal scrotalsonogram except for unilateral microlithiasis.

Flush et al2 reported a case in which a germ-celltumor was found 15 months after an initial ex-amination had disclosed unilateral microlithiasis.In our patient, the finding of metastatic diseaseprompted an extensive diagnostic workup that in-cidentally revealed tumor in a testis with micro-lithiasis.

Testicular microlithiasis has been associatedwith a number of other diseases. The most com-mon associations are cryptorchid testes,10 infer-tility,4 calcifications of the sympathetic nervoussystem,10 pulmonary alveolar microlithiasis,11

testicular torsion,12 and intratubular germ-cellneoplasia.13 The condition most commonly asso-ciated with testicular microlithiasis is infertilityor subfertility, present in 37% of cases; testiculartumor is the second most commonly associatedentity, occurring in 29% of cases.5 In Backus etal’s1 review, testicular malignancy occurred in40% of patients with testicular microlithiasis. Indescending order of frequency, the types of malig-nancy were seminoma, teratoma, and mixedgerm-cell tumor. Using a mammographic tech-nique to examine testicular specimens from 92patients, Ikinger et al14 found microcalcificationsin 32 (74%) of 43 testes with tumor versus 8 (16%)of 49 testes that were normal or had benign dis-ease. Whether testicular microlithiasis is an indi-rect indicator of a premalignant condition has yetto be elucidated.15 Nevertheless, because of thehigh frequency of primary testicular tumor in as-sociation with it, testicular microlithiasis cannot

FIGURE 1. Transverse sonogram of the testes through their midpor-tion. The multiple nonshadowing echogenic foci of calcifications areclearly seen within the substance of the right (R) testis. The left (L)testis has a normal echotexture.

FIGURE 2. Longitudinal sonogram of the right testis. The multipleechogenic foci characteristic of testicular microlithiasis are demon-strated in the right testis. In addition, a small hypoechoic area repre-senting the seminoma (arrows) is demonstrated.

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continue to be considered a benign entity.1 As in-dicated by previous reports,2,3 serial sonographicexaminations at intervals no longer than 1 yearmay be warranted in patients with testicular mi-crolithiasis.

REFERENCES

1. Backus ML, Mack LA, Middleton WD, et al:Testicular microlithiasis: imaging appearancesand pathologic correlation. Radiology 1994;192:781.

2. Flush DP, Kliewer MA, Madden JF: Testicular mi-crolithiasis and subsequent development of meta-static germ cell tumor. AJR Am J Roentgenol 1996;167:889.

3. McEniff N, Doherty F, Katz J, et al: Yolk sac tumorof the testis discovered on a routine annual sono-gram in a boy with testicular microlithiasis. AJRAm J Roentgenol 1995;164:971.

4. Janzen DL, Mathieson JR, Marsh JL, et al: Tes-ticular microlithiasis: sonographic and clinical fea-tures. AJR Am J Roentgenol 1992;158:1057.

5. Miller RL, Wissman R, White S, et al: Testicu-lar microlithiasis: a benign condition with a ma-lignant association. J Clin Ultrasound 1996;24:197.

6. Vegni-Talluri M, Bigliardi E, Vanni MG, et al: Tes-

ticular microliths: their origin and structure. JUrol 1980;124:105.

7. Janzen DL, Mathieson JR: Testicular microlithia-sis and seminoma [letter]. Clin Radiol 1993;48:219.

8. Doherty FL, Mullins TL, Sant GR, et al: Testicularmicrolithiasis: a unique sonographic appearance. JUltrasound Med 1987;6:389.

9. Winter TC III, Zuncel DE, Mack LA: Testicularcarcinoma in a patient with previously demon-strated testicular microlithiasis. J Urol 1996;155:648.

10. Nistal M, Paniagua R, Diez-Pardo JA: Testicularmicrolithiasis in two children with bilateral crypt-orchidism. J Urol 1979;121:535.

11. Schantz A, Milsten R: Testicular microlithiasiswith sterility. Fertil Steril 1976;27:801.

12. Jaramillo D, Perez-Atayde A, Teele RL: Sonogra-phy of testicular microlithiasis. Urol Radiol 1989;11:55.

13. Sasagawa I, Nakada T, Kazama T, et al: Testicularmicrolithiasis in male infertility. Urol Int 1988;43:368.

14. Ikinger U, Worster K, Terwey B, et al: Microcalci-fications in testicular malignancy: diagnostic toolin occult tumor? Urology 1982;19:525.

15. Emberton P, Moody AR: Testicular microlithiasis[letter]. AJR Am J Roentgenol 1994;162:1002.

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