Striated pattern on scrotal ultrasonography: A marker for Non-hodgkins lymphoma of testis.

We present a case of 52 year old man who presented with bilateral painless testicular swelling. On evaluation with high resolution ultrasonography of the scrotum, typical "striated pattern" which is highly suggestive of Non Hodgkins lymphoma of the testis was seen. The patient underwent bilateral inguinal orchidectomy and the histopathological examination confirmed the diagnosis of Non Hodgkins lymphoma.

INTRODUCTION

Scrotal ultrasonography (US) is important in the evaluation of intra-scrotal pathology as it can evaluate size, shape, echo texture of testis and the paratesticular structures. Testicular malignancies are usually seen as hypoechoic lesions on gray scale US. In the past few years, striated appearance of the testis is being recognized more often on US and its implications are being understood. In a patient with painless enlargement of the testis, this pattern on US may represent non-Hodgkin's lymphoma (NHL). Herein, we report such a case.

CASE REPORT

A 52-year-old hypertensive male presented with progressively increasing painless, bilateral scrotal swellings of 6 months duration. Physical examination revealed a cachectic patient with moderately enlarged, uniformly firm testes with loss of testicular sensation on either side. Abdominal examination did not reveal any organomegaly. Basic biochemical investigations were normal. Serum alpha fetoprotein and beta human chorionic gonadotropin were normal. Serum lactate dehydrogenase was minimally elevated.

US of the scrotum showed striated pattern of both enlarged testicles [Figure 1]. Increased vascularity was seen in color Doppler study [Figure 2]. Chest X-ray and abdominopelvic computed tomography (CT) scan were normal. He underwent bilateral high inguinal orchidectomy. On the third post-operative day, he became unconscious and CT scan of the brain showed evidence of metastasis with mass effect. The patient expired on the same day.

Figure 1

High resolution sonography (10MHz) of the testicle showing the classical striated pattern

Figure 2

Color Doppler study showing increased vascularity of the lesion

Histopathological examination and immunohistochemical staining (CD20 +ve, CD79 +ve, CD3 −ve, CD5 −ve) confirmed bilateral B-cell type NHL.

DISCUSSION

With advances in US technology, finer details of testicular as well as paratesticular lesions are discerned more accurately. Of late, a specific appearance called “striated pattern” has been described on testicular US. It consists of multiple, hypoechoeic bands radiating from the mediastinum testis. Anatomically, this pattern corresponds to the interlobar septae fanning out from the mediastinum along which blood vessels and lymphatics travel. Processes, which involve these septae result in striated appearance.

Testicular pathologies such as seminoma, lymphoma, leukemia, fibrosis and orchitis may have this pattern on US. When clinical findings such as pain, mass and chronicity of symptoms are considered along with the US finding of striated testis, often it is possible to make a clinical diagnosis.

Emura et al. and Tweed et al. described striated testis in their patients with testicular lymphoma.[12] In elderly patients, bilateral testicular involvement with Hodgkin's lymphoma is not uncommon. In children and younger patients, with appropriate clinical findings leukemia and seminoma may be considered respectively.

Casalino et al. described the striated pattern in five patients who presented with testicular pain.[3] Of these, three patients had small testis and two normal testis. As the condition remained stable over a period of 1 year, the unilateral striated pattern of the testicle was considered to be due to the fibrosis. Cohn EL et al. have also reported a similar finding in testicular fibrosis.[4] The striated pattern has been described in patients with orchitis also.[5]

CONCLUSION

The differential diagnosis for a striated testis on US includes neoplasm, fibrosis and orchitis. Differentiation of these conditions can be based on relevant clinical history and findings.