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Testicular vasculopathy and haematoma

Macroscopically the cut surface of the testis showed variably sized focally coalescent dark brown nodular areas replacing most of the testis. The epididymis and spermatic cord were normal (Fig 1). Microscopically the nodular areas corresponded to parenchymal haematoma (Fig 2), adjacent to which were dilated blood-filled vessels (Fig 3). Some veins showed recanalising intraluminal thrombi (Fig 4). Occasional arteries showed intimal thickening and mural lymphohistiocytic infiltrate consistent with vasculitis (Fig 5). There was no fibrinoid necrosis of vessel walls. These vasculopathic changes were limited to the testis. Paratesticular and spermatic cord vessels were normal. The background testis showed mostly tubular atrophy and sclerosis with an associated interstitial chronic inflammatory cell infiltrate composed of lymphocytes and plasma cells (Fig 6). Focally seminiferous tubules (ST) showed spermatogonia with incomplete spermatogenesis and reactive changes including enlarged germ cells with clear cytoplasm resembling germ cell neoplasia in situ (GCNIS) (Fig 7). OCT4 immunohistochemistry (IHC) was negative. No parenchymal necrosis was seen. There was no evidence of malignancy.
The constellation of pathological changes in the current case are similar to those described in a series of 30 cases by Kao et al. [1]. The patients age ranged from 12 to 66 years (median 33 years). They clinically presented with testicular pain, testicular mass or both. The majority underwent orchidectomy because of clinical and imaging findings concerning for neoplasm. Histologically most showed parenchymal haemorrhage/haematoma and/or areas of necrosis, vasculopathic changes (in veins, arteries and indeterminate type vessels), dilated blood vessels, tubular atrophy and sclerosis, and reactive changes in ST mimicking GCNIS. The authors attributed these findings to chronic intermitted torsion rather than a manifestation of systemic vasculitis. The latter is an important consideration, however, it is usually characterised by fibrinoid vascular necrosis of small- to medium-sized arteries, neutrophilic infiltrate in vessel walls, leukocytoclastic changes and granulomatous inflammation [2]. Also, the patient does not have a history of systemic vasculitis. An important differential diagnosis is germ cell tumour such as choriocarcinoma with associated haematoma. In this case the whole testis was submitted for histological examination and no neoplastic trophoblast and or syncytitiotrophoblast cells were identified. Moreover GCNIS that is usually associated with germ cell tumours was excluded by negative OCT4 IHC. No features to suggest angiosarcoma including anastomosing vascular channels or solid sheets of high grade epithelioid or spindled cells with mitotic activity were identified.

1. Kao CS, Zhang C, Ulbright TM. Testicular hemorrhage, necrosis, and vasculopathy: likely manifestations of intermittent torsion that clinically mimic a neoplasm. Am J Surg Pathol. 2014 Jan;38(1):34-44.
2. Kariv R, Sidi Y, Gur H. Systemic vasculitis presenting as a tumorlike lesion. Four case reports and an analysis of 79 reported cases. Medicine (Baltimore). 2000 Nov;79(6):349-359.

Laurence A Galea (1), Sree Appu (2)
1. Department of Anatomical Pathology, Melbourne Pathology, Sonic Healthcare, Victoria, Australia
2. Department of Surgery, Monash University, Victoria, Australia

Twitter handle: @DrLaurenceGalea

Testis

Testicular vasculopathy, haematoma