Painless Scrotal Swelling
Radiology Cases in Pediatric Emergency Medicine
Volume 7, Case 12
Muhammad Waseem, MD
Lincoln Medical And Mental Health Center. Bronx, NY.
This is a 13 year old male with a chief complaint of
bilateral scrotal swelling. The swelling began a month
ago and has been gradually increasing. It is
associated with mild discomfort but no pain. He
complains of fatigue and two episodes of epistaxis in
the last month. There is no history of trauma or voiding
difficulties. Review of systems are otherwise negative
for fever, chills, headache, cough, abdominal pain,
weight loss or night sweats. He has no other significant
past medical history.
Exam: VS T 36.7 (oral), P 84, R 18, and BP 110/70.
He is healthy appearing and comfortable. He has
significant bilateral scrotal swelling with the skin taut
and erythematous. The right hemiscrotum measures 8
cm x 4 cm. The left hemiscrotum is 8.5 cm x 4 cm. The
scrotal swelling is firm, non-tender and does not
transilluminate. There is no clinical evidence of
organomegaly, lymphadenopathy or an abdominal
mass. The remainder of the physical examination is
His WBC is 4,300 with 24% neutrophils, 64%
lymphocytes and 3% eosinophils. A review of the
peripheral smear is negative for blast cells. Since
systemic diseases such as lymphoma may present as a
testicular mass, a chest radiograph was obtained.
View his CXR.
His chest radiographs reveal an anterior mediastinal
mass. The PA view shows a widened mediastinum.
Note the abnormal contour of the mediastinal shadow
above the heart. The lateral view shows a solid tissue
density in the region anterior and superior to the heart.
In infants, this region is filled with a thymic density.
However, in children, teens and adults, this region
should be occupied by lung tissue. A solid tissue
density is suggestive of a mediastinal mass (or right
The suggestion of a mediastinal mass in conjunction
with testicular swelling suggests the presence of a
neoplastic process. The common causes of testicular
swelling with a mediastinal mass include lymphoma,
leukemia and germ cell tumors.
His CBC does not show any signs of leukemia. Beta
HCG and Alpha-fetoprotein, both markers for germ cell
tumors, are normal. Testicular biopsy demonstrates
the presence of a lymphoblastic lymphoma. Bone
marrow examination does not show marrow
Lymphoma is the third most common neoplasm of
childhood after leukemia and central nervous system
(CNS) tumors (1). It is the most common anterior
mediastinal mass accounting for a quarter of all
mediastinal masses (2).
Pediatric Non-Hodgkin's lymphoma (NHL) accounts
for approximately 10% of cancers in children and
adolescents (3). The peak age of presentation is 9
years (2), and males outnumber females 3 to 1 (4).
Non-Hodgkin's lymphomas can usually be placed in
one of the three major subgroups: Burkitt's lymphoma,
lymphoblastic lymphoma and large cell lymphoma (3).
Patients with lymphoblastic lymphomas commonly
manifest as an intrathoracic tumor, particularly as a
mediastinal mass (50% to 70%) and often have pleural
effusions (4). More than 70% of the patients have
disseminated disease at the time of presentation (2).
Mediastinal masses are the most common thoracic
masses in children. Approximately 30% develop before
age 12. Approximately 30% occur in the anterior, 30%
in the middle, and 40% in the posterior compartment of
the mediastinum (2).
The diagnosis of lymphoma should be made
expeditiously, as it can disseminate rapidly. Diagnostic
studies should include complete blood count,
sedimentation rate, serum LDH, Beta HCG,
alpha-fetoprotein and a chest radiograph. Early
involvement of an oncologist is essential in order to
facilitate an appropriate work-up.
1. Any patient with painless testicular swelling not
associated with underlying inflammation, trauma or
infection should have a chest radiograph to identify the
presence of a mediastinal mass or parenchymal lung
2. The first step in evaluating a mediastinal mass
lesion is to place it in one of the three mediastinal
compartments, since each has its own differential
diagnosis. The most common lesions in the anterior
mediastinum are thymoma, lymphoma and teratoma.
The most common masses in the middle mediastinum
are vascular masses, lymph node enlargement from
metastases or granulomatous disease and
pleuropericardial and bronchogenic cysts. In the
posterior mediastinum, neurogenic tumors,
meningocele, meningomyelocele, gastroenteric cysts
and esophageal diverticula are commonly found (5).
Neurogenic tumors comprise 90% of the posterior
mediastinal masses in the pediatric age group.
Neuroblastoma is by far the most common followed by
ganglioneuroblastoma and ganglioneuroma.
Mediastinal neuroblastoma is also associated with a
more favorable prognosis when diagnosed in a child
before 1 year of age (2).
3. After identification of a mediastinal lesion on a
conventional radiograph, CT or MRI is the preferred
modality for further evaluation of the middle and
anterior mediastinum, whereas MRI is definitely the
preferred modality for posterior mediastinal lesions,
since most are neurogenic lesions which delineate
better with MRI because of its multiplanar capabilities
1. Gilchrist GS. Lymphoma. In: Behrman RE,
Kliegmman RM, Jenson HB (eds). Nelson Textbook of
Pediatrics, 16th edition. Philadelphia, W.B. Saunders
Company, 2000, pp1548-1552.
2. Blickman JG. Pediatric Radiology - The
Requisites. St. Louis, Mosby, 1994, pp36-41.
3. Philip T, Bergeron C, Frappaz D. Management
of paediatric lymphoma. Bailliere's Clinical
4. Shad A, Magrath I. Malignant Non-Hodgkin's
Lymphomas in Children. In: Pizzo PA, Polack DG
(eds). Principles and Practice of Pediatric Oncology,
3rd edition, Philadelphia, Lippincott-Raven
5. Light RW. Disorders of pleura, mediastinum and
diaphragm. In: Fauci AS, Braunwald E, Isselbacher
KJ, et al (eds). Harrison's Principles of Internal
Medicine, 14th edition. New York, McGraw-Hill Health
Professions Division, 1998, pp1472-1476.
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