In adults, malignant extratesticular neoplasms are rare and have a non-specific appearance . Mesothelioma is an uncommon neoplasm, which usually presents as a hydrocele, with soft tissue nodules of the tunica vaginalis. Alternatively, it may present as a large heterogeneous mass, which may be difficult to separate from the testis. Mesotheliomas tend to occur in individuals who are decades older than those typically diagnosed with tes-ticular germ cell tumors.
Lymphoma may occasionally involve the epididymis, although in the majority of patients this does not lead to a diagnostic dilemma as (1) the patient will be known to have lymphoma and (2) there will be coexistent involvement of the testis itself. Very rarely, solid tumors may metastasize to the epididymis. Affected patients almost always have advanced disease elsewhere throughout the body.
The most common extratesticular intrascrotal neoplasm is lipoma, which arises from the spermatic cord and can often be diagnosed clinically based on palpation. Adenomatoid tumors are nearly as common as lipomas, and account for about one third of extratesticular masses. These are benign, but may be surgically removed either to establish the diagnosis or because of local pain or ten derness. They are solid, well-marginated lesions that are typically less than 20 mm in size. They most frequently arise from the epididymis.
Papillary cystadenomas of the epididymis are seen in about one quarter of patients with von Hippel-Lindau disease (VHL). The lesions are rare in individuals without VHL. They are typically solid, measure between 1 and 5 cm, and may be indistinguishable from adenomatoid tumors .
Sarcoidosis is more likely to affect the epididymis than the testis. More than one third of patients will have bilateral disease. Although discrete nodules will occasionally be seen, the appearance is more commonly one of heterogeneous enlargement. A diagnostic pattern that may be of use in a previously undiagnosed patient with hilar adenopathy (which could be either lymphoma or sarcoid), is to compare the testicular and the epididymal involvement: in sarcoidosis, the degree of epididymal disease typically exceeds testis involvement, whereas in lymphoma the converse is expected.
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