|Year : 2016 | Volume
| Issue : 3 | Page : 176-178
Testicular leiomyoma masquerading as lymphoma
P Arul, C Akshatha
Department of Pathology, Dhanalakshmi Srinivasan Medical College and Hospital, Perambalur, Tamil Nadu, India
|Date of Web Publication||28-Sep-2016|
83, Ayyanar Kovil Street, Vinayagampet, Sorapet Post, Puducherry - 605 501
Source of Support: None, Conflict of Interest: None
Leiomyomas are benign tumors which arise from smooth muscle cells. They are usually seen in the uterus and other organs. In the genitourinary tract, the renal capsule is most commonly involved; however, leiomyoma involving testis is extremely rare. We describe the case of a 63-year-old male patient presented with painless swelling of the right scrotum for 2 years with gradual increasing in size. Ultrasonography of scrotum revealed well-defined hypoechoic mass in the right testis just beneath the tunica albuginea layer; hence, a diagnosis of testicular lymphoma was made. However, leiomyoma was confirmed by histopathological examination. This case highlights the rare occurrence and also it can mimic as malignancy.
Keywords: Leiomyoma, lymphoma, testis
|How to cite this article:|
Arul P, Akshatha C. Testicular leiomyoma masquerading as lymphoma. J Med Soc 2016;30:176-8
| Introduction|| |
Leiomyomas are benign tumors more commonly found in the uterus and also been described in nearly every organ and every location in the soft tissue. Pathophysiology of these benign neoplasms not well understood, but genetic predisposition, steroid hormones, growth factors, and angiogenesis plays an important role in the development of leiomyoma.  Leiomyomas involving intrascrotal structures are infrequently seen and most originate from the epididymis, accounting for 6% of all epididymal tumors.  However, leiomyoma of the testis and spermatic cord are extremely rare.  This tumor can be mistaken for malignancy by its ultrasonographic findings. We report here the extremely rare case of leiomyoma of testis which was mimicking lymphoma ultrasonographically.
| Case report|| |
A 63-year-old male presented with right-sided scrotal swelling for the past 2 years. The swelling was gradually increasing in size without any pain. Physical examination revealed an enlarged, firm to hard, well demarcated, nontender swelling approximately measuring 2 cm diameter in the right testis. The right epididymis and spermatic cord and also left testis, epididymis, and spermatic cord were unremarkable. Bilateral inguinal lymph nodes were not palpable. Parameters of complete blood count and routine biochemical investigations were within normal limits. Ultrasonography of scrotum showed well-defined hypoechoic and hypervascular mass in the right testis just beneath the tunica albuginea layer, measuring 1.9 cm × 1.7 cm in size. The left-sided testis and spermatic cord were normal. With these ultrasonographic findings, a diagnosis of testicular lymphoma was made. Under spinal anesthesia, right orchidectomy was performed. Postoperative course was uneventful.
Grossly, the involved testis measuring 4 cm × 3 cm × 1.5 cm with a mass measuring 2 cm × 2 cm × 1.2 cm. Cut surface showed a well circumscribed, gray-white firm mass involving upper pole along with residual normal appearing testis [Figure 1]. There was no evidence of necrosis on gross examination. The epididymis and spermatic cord were not involved by tumor. Microscopically, well-circumscribed tumor composed of spindle-shaped cells arranged in interlacing bundles and fascicles noted within the testicular parenchyma. The tumor cells having centrally placed blunt-ended elongated vesicular nuclei and eosinophilic cytoplasm [Figure 2],[Figure 3] and [Figure 4]. There was no evidence of nuclear atypia/mitosis/coagulative tumor necrosis or lymphoma. Hence, the diagnosis of leiomyoma was made. There was no involvement of tunica albuginea microscopically.
|Figure 1: Cut surface of right testis showing well circumscribed grey white lesion in the upper pole with residual normal appearing parenchyma|
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|Figure 2: Photomicrograph of right testis showing well circumscribed leiomyoma with adjacent normal appearing seminiferous tubules (H and E, ×100)|
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|Figure 3: Photomicrograph of right testis showing interlacing bundles and fascicles of smooth muscle cells (H and E, ×100)|
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|Figure 4: Photomicrograph of right testis showing smooth muscle cells with blunt ended elongated vesicular nuclei without any nuclear atypia/mitosis/necrosis (H and E, ×400)|
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| Discussion|| |
In 1972, Albert and Mininberg reported the first case of testicular leiomyoma.  The genitourinary leiomyomas are more commonly found in the renal capsule, but the involvement of testis is extremely rare.  The origin of testicular leiomyoma is controversial. It is thought to be caused by the proliferation of muscle bundles from the smooth muscle in the vascular tree. 
When a patient presents with any scrotal mass, must be properly evaluated and investigated to rule out the possibility of malignancy such as seminoma. In our case, a diagnosis of testicular lymphoma was made ultrasonographically as it was showed well-defined hypoechoic and hypervascular mass within the right testis. However, leiomyoma was confirmed by histopathological examination. Hence, while evaluating the testicular mass by ultrasonography, one should also consider leiomyoma as one of the differential diagnoses. The possible histopathological differential diagnosis is an inflammatory myofibroblastic tumor (IMT) of the spermatic cord.  Histologically, three patterns have been described in IMT such as myxoid/vascular, compact spindle cell pattern and hypocellular fibrous pattern. All these patterns, composed of spindle-shaped cells of varying proportion having oval to spindle-shaped vesicular nuclei, small-sized nucleoli and eosinophilic to amphophilic cytoplasm along with the heterogeneous population of inflammatory cells such as plasma cells, lymphocytes, and eosinophils.  Whereas, in our case, we noted interlacing bundles and fascicles of spindle-shaped cells without any inflammatory cell infiltrate. IMT is usually associated with antecedent hydrocele in 45% of cases and trauma or infection in 30% of cases.  However, in this case report, the patient had no history of hydrocele/trauma/infection; hence, we strongly suggesting that this a leiomyoma rather than IMT. Immunohistochemically leiomyomas show cytoplasmic positivity for smooth muscle actin, desmin, and caldesmon and negative for S100 protein. However, myofibroblast of IMT also show positivity for smooth muscle actin, but only at the periphery of the cytoplasm which resembles the "tram-tract" pattern. 
| Conclusion|| |
Leiomyoma of testis is an extremely rare benign tumor. We present this case primarily due to its rarity and curability. Leiomyoma can be a possible differential diagnosis in the evaluation of scrotal mass, and all the cases require histopathological confirmation for proper management.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]