What are the implications and management of a right scrotal calcification found on ultrasound?

Management of Right Scrotal Calcification on Ultrasound

Scrotal calcifications detected on ultrasound require further evaluation to rule out testicular malignancy, especially when the calcification is intratesticular, as this finding may represent a necrotic germ cell tumor or other pathology requiring surgical intervention.

Classification and Risk Assessment

Scrotal calcifications can be categorized based on location and pattern:

Intratesticular Calcifications

• Multiple and grouped intratesticular calcifications (microlithiasis):

  • If isolated finding without other risk factors: No increased risk of malignancy 1
  • If accompanied by risk factors (cryptorchidism, prior testicular cancer, family history): Increased risk of germ cell testicular tumor (GCTT) 1

• Focal intratesticular calcification:

  • Highly suspicious for malignancy, especially in necrotic areas of germ cell tumors 2
  • May also represent epidermoid cyst, granulomatous orchitis, or old hematoma 2

Extratesticular Calcifications

• Usually benign 2
• May be associated with hydrocele, epididymal appendage, or scrotal calcinosis 3, 4

Diagnostic Approach

1. Detailed ultrasound assessment:

   • Determine exact location (intratesticular vs. extratesticular)
   • Assess size, number, and arrangement of calcifications
   • Evaluate for associated masses or abnormalities
   • Use color Doppler to assess vascularity 1

2. Laboratory evaluation (if intratesticular calcification or suspicious findings):

   • Serum tumor markers: AFP, β-hCG, LDH 1
   • Complete blood count, liver enzymes, creatinine, electrolytes 1

Management Algorithm

For Extratesticular Calcifications:

• Generally benign
• Clinical follow-up without specific intervention
• Consider repeat ultrasound in 6-12 months to ensure stability

For Intratesticular Calcifications:

1. Isolated testicular microlithiasis without other abnormalities:

   • No further evaluation or follow-up needed 1
   • Patient education on testicular self-examination

2. Focal intratesticular calcification or calcification with associated mass:

   • Surgical exploration via radical inguinal orchiectomy is indicated 1
   • This serves both diagnostic and therapeutic purposes
   • Sperm banking should be discussed before surgery 1

3. Testicular microlithiasis with risk factors (cryptorchidism, family history, prior testicular cancer):

   • Annual ultrasound surveillance 5
   • Regular testicular self-examination
   • Monitoring of tumor markers

Special Considerations

• Fertility preservation: Discuss sperm banking before any surgical intervention, especially if there is significant testicular volume loss or bilateral involvement 1

• Diagnostic pitfalls:

  • Testicular tumors can sometimes present as epididymal disease, leading to misdiagnosis 6
  • Sensitivity of ultrasound for testicular malignancy is approximately 98% 6
  • Some benign conditions (orchitis, epidermoid cyst, granuloma) can mimic malignancy on imaging 2

• Follow-up recommendations:

  • If surgical management is deferred, regular ultrasound follow-up is essential to monitor for changes
  • Patients with risk factors require more vigilant surveillance

Conclusion

The finding of right scrotal calcification on ultrasound requires careful assessment of location, pattern, and associated abnormalities. Intratesticular calcifications, particularly when focal or associated with a mass, warrant surgical exploration due to high suspicion for malignancy, while isolated microlithiasis without risk factors can be managed conservatively.