AJR 2005; 184:S102-S103
© American Roentgen Ray Society
Radiation-Induced Fibrosis of the Spermatic Cord: Sonographic and MRI Findings
Allison Aguado1,
Thomas H. Grant1,
Frank H. Miller1 and
John Garnett2
1 Northwestern University, Department of Radiology, 676 N St. Clair St., Suite
800, Chicago, IL 60611.
2 Northwestern University, Department of Urology.
Received February 23, 2004;
accepted after revision April 15, 2004.
Address correspondence to T. H. Grant
(t-grant{at}northwestern.edu).
Introduction
Fibrosis is a well-known complication of radiation therapy. The
consequences of therapy can be obvious or subtle and can occur months to years
after the completion of treatment.
Available data concerning irradiation of the male reproductive system show
potential effects that may include decreased testicular volume, erectile
dysfunction, infertility, and decreased libido
[1]. We report the sonographic
and MRI findings of a case of radiation-induced spermatic cord fibrosis which,
to our knowledge, has not been reported in the literature.
Case Report
A 26-year-old man with a history of stage IV rhabdomyosarcoma of the
bladder as a child presented with a painful, small, indurated left
extratesticular mass in the superior aspect of the scrotum. The left testis
was located adjacent to the mass. The patient noted a palpable lump about a
month before presentation, which he described as the size of a pea. When the
patient was 18 months old, a stage IV rhabdomyosarcoma of the urinary bladder
was resected. At that time, the patient was treated with triple chemotherapy
(cyclophosphamide, vincristine, dactinomycin) and radiation therapy. A total
of 4,200 cGy to the pelvis and 3,000 cGy were administered to the entire
abdomen. Several years earlier, bilateral hip hemiarthroplasties were
performed for radiation-induced osteonecrosis.
The region was initially assessed with sonography using a 12-MHz
transducer. The left testis measured 3.2 x 1.9 x 2.6 cm and the
right, 2.1 x 2.9 x 1.5 cm. Both contained a few small
calcifications. Color Doppler imaging revealed the presence of symmetric flow
to the testes. The left testis was abnormally positioned just inferior to the
external ring. The epididymides were normal. A 1.4 x 0.5 x 0.9 cm
heterogeneous echogenic mass was detected in the left spermatic cord that
extended into the left inguinal canal (Figs.
1A and
1B). Both the left testis and
spermatic cord mass were tender to transducer pressure.
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Fig. 1A. —26-year-old man with history of stage IV rhabdomyosarcoma of
bladder as a child presented with painful, small, indurated left
extratesticular mass in superior aspect of scrotum. Longitudinal sonogram of
left testis shows cluster of microcalcifications (arrowheads).
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Fig. 1B. —26-year-old man with history of stage IV rhabdomyosarcoma of
bladder as a child presented with painful, small, indurated left
extratesticular mass in superior aspect of scrotum. Contiguous sagittal images
of left testis (arrows) and spermatic cord mass
(arrowheads).
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MRI examination of the pelvis and scrotum was performed with a 1.5-T
magnet. The pulse sequences were T1-weighted axial images, axial HASTE, and T2
turbo spin echo. Dynamic spoiled gradient echo T1-weighted imaging was
performed with fat suppression before and after 20 mL of IV gadopentetate
dimeglumine (Magnevist; Berlex) was administered. MRI showed diffuse
thickening with low signal intensity of the left spermatic cord that extended
into the inguinal canal (Fig.
1C). There was only minimal contrast enhancement of the left
spermatic cord. Because of magnetic susceptibity artifacts caused by the
bilateral hip hemiarthroplasties, fat suppression was poor and it was
difficult to interpret the post-contrast MR images. No pathologic adenopathy
or pelvic masses were seen. Because of continuous pain and the uncertain
etiology of the imaging findings, surgery was performed. After sperm
preservation, left inguinal orchiectomy was performed. The testes and
spermatic cord were resected, since both were abnormal to palpation at
surgical exploration. Pathology demonstrated fibrosis and marked thickening of
the entire left spermatic cord consistent with radiation changes. The left
testis and epididymis also showed changes of radiation fibrosis. Testicular
and spermatic cord tissue was negative for malignancy.
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Fig. 1C. —26-year-old man with history of stage IV rhabdomyosarcoma of
bladder as a child presented with painful, small, indurated left
extratesticular mass in superior aspect of scrotum. Coronal T2-weighted turbo
spin-echo image (TR/TE, 7,804/136; flip angle, 180°) shows thickened
spermatic cord extending into the inguinal canal (arrows). Left
testis is pulled superiorly toward the external ring (arrowhead).
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Discussion
As more children with cancer survive after therapy, the obligation grows
for physicians to critically assess the adverse effects of therapy
[2]. Neither the threshold dose
of irradiation required to damage the germinal epithelium nor the dose above
which irreversible damage occurs in childhood is known
[3]. The use of radiation
therapy to manage pediatric cancer is partly determined by the knowledge of
the late effects of radiation on normal tissue. Late effects have their onset
months to years after treatment is terminated
[2] and are related to the
irradiated site, dose of radiation, and the age of the child at the time of
treatment [4].
Radiation damage is produced by a combination of parenchymal cell loss and
injury to the underlying vasculature. Late changes observed in blood vessels
are mainly characterized by arteriole changes such as hyaline, fibrinoid, and
collagenous thickening of blood vessel walls. Besides fibrosis, complications
of pelvic irradiation include cystitis, hematuria, fistula formation
[5], gonadal failure,
ejaculatory dysfunction, urethral strictures associated with urethritis, bone
or soft tissue hypoplasia, and secondary malignancies
[6].
The differential diagnosis of inguinal and scrotal pathology includes
testicular torsion, epididymoorchitis, trauma, varicocele, spermatoceles,
hydroceles, testicular neoplasm, and hernia
[7]. These abnormalities can
usually be differentiated by the use of sonography. The presentation of a
painful spermatic cord mass caused by radiation fibrosis has not been
previously described, to our knowledge. The etiology of the scrotal pain is
unclear. It could have been related to ischemia caused by traction of the
testis by the abnormal spermatic cord or radiation-induced vascular damage to
the testicular artery. Because of the severity of the left scrotal pain,
surgical exploration and a radical orchiectomy were performed.
The sonographic and MRI findings clearly delineated the nodular, thickened
spermatic cord extending into the inguinal canal. Radiation fibrosis should be
considered in the appropriate clinical setting and in patients presenting with
pain and a spermatic cord mass, despite an initial presentation approximately
25 years earlier.
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Introduction
Case Report
