Ramiro J. Madden-Fuentes, MD
Judd W. Moul, MD, FACS
BASICS
DESCRIPTION
• Adenomatoid tumors are benign lesions of the male testicular adnexa.
• Usually ∼1 cm in size (range 0.5–7.5 cm) (1)[C]
• Most often asymptomatic
• Mesenchymal origin (2)[C]
EPIDEMIOLOGY
Incidence
• The majority of patients present within the 3rd–5th decades of life (3)[C].
• Adenomatoid tumors are the most common neoplastic processes involving the testicular adnexal and spermatic cord structures (3)[C].
• Adenomatoid tumors in females occur in uterus > fallopian tubes > ovary (1)[C].
Prevalence
Not well defined
RISK FACTORS
None described
Genetics
N/A
PATHOPHYSIOLOGY
• Mesothelial origin is most accepted theory (3)[C]
• Benign with no reported cases of metastasis
• Capable of local invasion
• Epididymis, tunica vaginalis, spermatic cord are most common sites
ASSOCIATED CONDITIONS
N/A
GENERAL PREVENTION
• Routine self-exam for identification of scrotal content masses
• Routine genital exam by physician
DIAGNOSIS
HISTORY
• Duration of lesion and size
• Interval growth
• Associated pain, dysuria, tenderness – epididymitis
• Prior malignancy or scrotal pathology
• Exposure to tuberculosis (TB)
• History of sarcoidosis, histoplasmosis
• History of urinary tract infection or sexually transmitted infection
• Recent GU manipulation – bacillus Calmette–Guérin (BCG) instillation
PHYSICAL EXAM
• Scrotal exam
– Identify location of mass – single or multiple
– Evaluate for varicocele or hydrocele
– Compare with contralateral scrotal contents
– Evaluate if fixed, mobile, indurated, or encroaching on other structures
– Evaluate for spermatic cord involvement
– Transillumination – to identify if fluid filled (spermatocele, hydrocele)
• Inguinal exam
– Evaluate for lymphadenopathy
– Hernia
DIAGNOSTIC TESTS & INTERPRETATION
Lab
– Tumor markers if concern for testicular mass – α-fetoprotein (AFP),
– β-human chorionic gonadotropin (β-HCG)
– Lactate dehydrogenase (LDH)
Purified protein derivative (PPD) if TB suspected
No specific labs to diagnose adenomatoid tumors
Imaging
• Scrotal ultrasound
– Solid vs. cystic
– Location – testicular or paratesticular
If located in the tunica albuginea can grow into the testicular parenchyma and resemble a testicular malignancy
– Vascular or avascular
Diagnostic Procedures/Surgery
• Excision via inguinal approach
• Frozen section for pathology – proceed to orchiectomy with high cord ligation if malignant
Pathologic Findings
• Gross
– Small (1 cm), well circumscribed without fibrous capsule
– Tan-white, homogeneous
• Microscopic
– Adenomatoid cells within fibrous stroma
– Occasional cystic dilation
– Irregular, somewhat branched-appearing tubular structures appear within the tumor, a coalescence of the cellular vacuoles, which form a false lumen (4)[C]
DIFFERENTIAL DIAGNOSIS
• Benign tumors of epididymis:
– Leiomyoma
– Papillary cystadenoma (associated with von Hippel–Lindau syndrome)
– Lipomas
– Hamartomas
– Adrenal cortical adenomas
• Malignant tumors of the epididymis:
– Sarcoma (rhabdomyosarcoma, leiomyosarcoma, fibrosarcoma, liposarcoma)
– Melanotic neuroectodermal tumor of the epididymis
• Extension of primary testicular tumor
• Metastatic tumor to epididymis:
– Urologic (prostate, kidney)
– GI (stomach, colon, carcinoid, pancreas)
• Other lesions of the epididymis
– Granuloma (sperm, TB, sarcoidosis)
– Spermatocele
– Epididymitis
– Epidermoid inclusion cyst
– Epididymal abscess
TREATMENT
GENERAL MEASURES
• Excision via inguinal approach – for benign lesions
• Epididymitis – consider sexually transmitted infection as source in young men and treat accordingly (see Sexually Transmitted Infections section)
MEDICATION
First Line
N/A
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Excision of suspicious lesion via inguinal approach with proximal vascular control
• Frozen section
• If positive for malignancy, radical orchiectomy
• Further surgical therapy guided by pathology but may include retroperitoneal lymph node dissection if rhabdomyosarcoma
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
Adenomatoid tumors are uniformly benign with no well-documented cases of true invasion, metastasis, or recurrence after excision (3)[C]
COMPLICATIONS
Scrotal hematoma, pain, infection
FOLLOW-UP
Patient Monitoring
• Oncologic follow-up if malignant disease
• Patient testicular self-exam
Patient Resources
http://www.aafp.org/afp/1998/0215/p685.html
REFERENCES
1. Wachter DL, Wünsch PH, Hartmann A, et al. Adenomatoid tumors of the female and male genital tract. A comparative clinicopathologic and immunohistochemical analysis of 47 cases emphasizing their site-specific morphologic diversity. Virchows Arch. 2011;458(5):593–602.
2. Delahunt B, Eble JN, King D, et al. Immunohistochemical evidence for mesothelial origin of paratesticular adenomatoid tumor. Histopathology. 2000;36:109–115.
3. Montgomery JS, Blood DA. The diagnosis and management of scrotal masses. Med Clin North Am. 2011;95(1):235–244.
4. Amin MB. Selected other problematic testicular and paratesticular lesions: Rete testis neoplasms and pseudotumors, mesothelial lesions and secondary tumors. Mod Path. 2005;18:S131–S145.
ADDITIONAL READING
• Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR. 2010;59 (No. RR-12)
• Montgomery JS, Blood DA. The diagnosis and management of scrotal masses. Med Clin North Am. 2011;95(1):235–244.
• Rubenstein RA, Dogra VS, Seftel AD, et al. Benign intrascrotal lesions. J Urol. 2004;171:1765–1772.
See Also (Topic, Algorithm, Media)
• Adenomatoid Tumors, Testicular and Paratesticular Image 
• Epididymis, Cystadenoma
• Epididymis, Metastasis to
• Epididymitis
• Paratesticular Tumors, General
• Sexually Transmitted Infections
• Spermatocele
• Testis, Tumor and Mass, Adult, General
• Testis, Tumor and Mass, Pediatric, General Considerations
• Von Hippel–Lindau Disease
CODES
ICD9
• 222.0 Benign neoplasm of testis
• 222.3 Benign neoplasm of epididymis
• 222.8 Benign neoplasm of other specified sites of male genital organs
ICD10
• D29.8 Benign neoplasm of other specified male genital organs
• D29.20 Benign neoplasm of unspecified testis
• D29.30 Benign neoplasm of unspecified epididymis
CLINICAL/SURGICAL PEARLS
• Adenomatoid tumors are benign with no reported metastasis.
• Excision via inguinal approach with proximal vascular control preferred.
• Treatment for epididymitis is guided by risk of sexually transmitted infections as a source.
• Ultrasound is important to delineate a testicular vs. paratesticular origin of the mass.