| Abstract|| |
Testicular hemangioma is a very rare benign vascular neoplasm, mostly occurring in children and young adults. We present a case of capillary hemangioma of the testis in a twenty three years old male who presented with painless mass in the right scrotum of 2 months duration. He was diagnosed with a right testicular tumor based on the physical examination, ultrasonography and magnetic resonance imaging studies. Serum tumor markers were normal. Right radical orchiectomy was performed. On histology, the tumor was diagnosed as capillary hemangioma of the testis. Immunohistochemical staining for CD31 and factor VIII confirmed the vascular nature of the tumor. To our knowledge, there are only twenty two cases of testicular hemangiomas reported in the literature. Although it is a rare tumor, surgeons and pathologists should be aware of it especially with the negative tumor marker findings. Intra-operative frozen section examination may be requested as tumor enucleation with testicular sparing surgery is considered adequate.
Keywords: Hemangioma, testis, testicular tumor
|How to cite this article:|
Zaidi SN, Fathaddin AA. Testicular capillary hemangioma - A case report of a rare tumor. Indian J Pathol Microbiol 2012;55:557-9
| Introduction|| |
Most testicular neoplasm in children and young adults are malignant tumors of germ cell origin.  Benign tumors including hemangiomas are extremely rare. The sonographic appearance of testicular hemangioma is poorly documented and therefore it is impossible to diagnose it preoperatively. This is the reason most of the patients undergo radical orchidectomy and the diagnosis is only established after the surgery. Here we present a rare case of typical testicular capillary hemangioma in a twenty three years old male patient.
| Case Report|| |
A twenty three years old male with unremarkable past history presented in the urology clinic for evaluation of the right testicular discomfort of 2 months duration. There was no history of trauma or accident. On urogenital examination, a palpable right testicular tender mass was identified. The multiplanar magnetic resonance imaging revealed an exophytic lobulated mass lesion measuring 1.6 × 1.5 cm, arising from the lower pole of the right testis which on Doppler ultrasound demonstrated high vascular flow [Figure 1]. The remaining right testicle and the left testicle were unremarkable. Serum tumor markers values (β human chorionic gonadotropin, α-feto protein and lactate dehydrogenase) were normal. The clinical and radiological diagnosis of probable testicular malignancy was made and the patient underwent right radical orchidectomy.
|Figure 1: Ultrasonographic findings: Ultrasonography revealed a well defined mass with homogenous echogenicity measuring 1.5 cm × 1.6 cm, demonstrating high vascular flow on Doppler Ultrasound|
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The gross pathologic examination revealed a 1.5 cm circumscribed lobulated grey tan mass attached to the lower pole of testis, not involving the tunica vaginalis, albuginea or epididymis. Microscopically, the tumor was composed of proliferation of capillary sized vascular spaces lined by flat endothelial cells and containing red blood cells [Figure 2]. The surrounding seminiferous tubules were unremarkable. The immunohistochemical staining for CD34 and factor VIII related antigen highlighted the endothelial cells lining the vascular spaces [Figure 3] confirming the vascular nature of this tumor. Stains for α-feto protein, inhibin and CAM5.2, were negative.
|Figure 2: Hematoxylin and Eosin stain showing capillary sized vascular spaces lined by flat endothelial cells and containing red blood cells (Original magnification ×400)|
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|Figure 3: Immunohistochemical staining for CD34 highlighting the endothelial cells lining the vascular spaces (Original magnification ×200)|
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On the basis of the characteristic morphologic and immunohistochemical findings, the diagnosis of testicular capillary hemengioma was rendered. At the last follow-up, 7 months after the operation, the patient was well without any clinical evidence of recurrence.
| Discussion|| |
Hemangiomas of the soft tissue are the most common benign tumors of vascular origin. However testicular capillary hemangiomas are quite rare with only approximately twenty two reported cases in the English literature.  Four histological types ofbenign testicular vascular tumors are reported: cavernous hemangiomas, capillary hemangiomas, histiocytoid and papillary endothelial hyperplasia.  Our case is a capillary type hemangioma. Patient usually presents with testicular enlargement with or without tenderness.  Our patient had pain in the right testis. The reported age range includes patients less than 1 year to those older than seventy years.  Serum tumor markers (α-feto protein, β human chorionic gonadotropin) are usually within normal limits. ,
On gross examination, the tumors are unencapsulated lesions that are often approximately 1 cm in greatest dimension, the largest reportedly measuring 3.7 cm which replaced the testicle.  The cut surfaces are tan-pink to red and homogenous. Histologically the mass is sharply defined, not encapsulated and made up of vascular spaces, partly or completely filled with blood separated by scant connective tissue. They are lobulated aggregates of closely packed thin walled capillaries and lined by flattened epithelium. Necrosis and mitotic activity are absent. The neoplastic vessels occasionally surround seminiferous tubules at the periphery of the lesion.  The adjacent testicular parenchyma is otherwise unremarkable. The differential diagnosis includes germ cell tumors (seminoma, teratoma) and sex-cord stromal tumors. The presence of proliferative capillary sized vascular spaces lined by flat endothelial cells and containing red blood cells are the most important microscopic evidence for a definitive diagnosis of capillary hemangioma. By immunohistochemistry, the cells lining the vascular channels are positive for endothelial markers (CD31, CD34, factor VIII, vimentin), vascular endothelial growth factorand are negative for epithelial antigens (such as cytokeratins and epithelial membrane antigen). ,,,
| Conclusion|| |
Hemangioma of the testis is a very rare benign tumor. Clinical appearance and diagnostic exams are usually not sufficient for the definite diagnosis and requires a histopathological examination. However if the surgeons and pathologists are aware of it; especially with negative tumor marker findings, conservative surgical treatment by means of tumor enucleation with preservation of the testis is possible if intra operative frozen section examination can be performed.
| References|| |
|1.||Suriawinata A, Talerman A, Vapnek JM, Unger P. Hemangioma of the testis: Report of unusual occurrences of cavernous hemangioma in a fetus and capillary hemangioma in an older man. Ann Diagn Pathol 2001;5:80-3. |
|2.||Mungan S, Turgutalp H, Ersöz S, Keskin F, Kutlu O. A rare neoplasm of the testis: Capillary hemangioma. Turk Patoloji Derg 2011;27:80-3. |
|3.||Stille JR, Nasrallah PF, McMahon DR. Testicular capillary hemangioma: An unusual diagnosis suggested by duplex color flow ultrasound findings. J Urol 1997;157:1458-9. |
|4.||Takaoka E, Yamaguchi K, Tominaga T. Cavernous hemangioma of the testis: A case report and review of the literature. Hinyokika Kiyo 2007;53:405-7. |
|5.||Mazal PR, Kratzik C, Kain R, Susani M. Capillary haemangioma of the testis. J Clin Pathol 2000;53:641-2. |
|6.||Uchida K, Takahashi A, Miyao N, Takeda K, Tsutsumi H, Satoh M, et al. Juvenile hemangioma of the testis: Analysis of expression of angiogenic factors. Urology 1997;49:285-6. |
|7.||Atkin G, Miller M, Clarkson KS, Molyneux AJ. Testicular capillary haemangioma in a child. J R Soc Med 2001;94:638-40. |
|8.||Talmon GA, Stanley SM, Lager DJ. Capillary hemangioma of the testis. Int J Surg Pathol 2011;19:398-400. |
Shaesta N Zaidi
Registrar, Histopathology/Cytopathology, Department of Pathology, King Khalid University Hospital, King Saud University, Riyadh-11461
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]