The estimated incidence of testicular torsion in men is 4.5 per 100,000 [
4], and the incidence of TGCT in men during their lifetime is 5.1 per 100,000 [
6]. TGCT with contralateral testicular torsion is still extremely rare. There have been some case reports of TGCT with ipsilateral testicular torsion, most detected after presenting with acute scrotal pain as a symptom of torsion. The causes of TGCT with developed torsion remain unclear, but there is a report that 96% of patients with testicular torsion have anatomical variations, such as bell clapper deformity and a long mesorchium [
7]. Srinivasan
et al. reported that hyperactivity of the cremasteric reflex, stimulated by cold weather, has been postulated as the physiopathology of acute testicular torsion [
8].
In general, the differential diagnosis to distinguish from bilateral TGCT is important because the intraoperative approaches, such as ligation of the spermatic cord and the site of incision, are significantly different depending on whether the testis is cancerous. In fact, the incidence of bilateral TGCT in patients with a TGCT has been reported as 1 to 3% [
9], and patients with seminoma were especially at significantly higher risk for bilateral disease than those with a nonseminomatous germ cell tumor. In our patient, his right testis was diagnosed with hemorrhagic infarction with torsion by MRI, intraoperative and histopathological findings. Microscopic examination revealed markedly dilated vessels caused by torsion. These findings proved the diagnosis as a testicular infarction, not a tumor.
Most solid intratesticular masses should be considered malignant, and radical orchiectomy is the treatment of choice. To avoid unnecessary orchiectomy, however, it is extremely important to recognize the imaging features of various benign intratesticular mass lesions, including orchitis, hemorrhage, ischemia and infarction, fibrosis, and dilatation of the rete testis. Cohen
et al. reported the first case of a testicular mixed germ cell tumor with contralateral testicular torsion [
10]. Although they mainly used a radionuclide scrotal scan to diagnose the torsion, it would not be useful for other scrotal disorders. Although Doppler ultrasonography and contrast-enhanced CT imaging are often used as diagnostic tools for acute scrotal disease, including torsion, inconclusive results may often be observed and their efficacy depends on the operator’s skill [
11]. Dynamic contrast-enhanced subtraction MRI could provide information about testicular perfusion and is useful to diagnose scrotal disorders [
12]. Diffusion-weighted MRI can also enable the detection of testicular torsion [
11]. Tsili
et al. indicated that the sensitivity, specificity and accuracy of MRI in the diagnosis of malignant testicular tumors were 100%, 87.5% and 96.4%, respectively [
13]. The advantages of this technique include the acquisition of precise anatomic information, satisfactory tissue contrast, and imaging in various planes. MRI is an efficient diagnostic tool for the evaluation of testicular masses, especially in preoperative differentiation, as in our case. In addition, it is important to preserve postoperative fertility in patients with both unilateral and bilateral TGCTs. The most effective means of preserving fertility in these patients is sperm cryopreservation before the initiation of cancer-directed therapy [
14]. In this case, we could preserve his sperm before orchiectomy and avoid a hasty operation with useful findings from MRI.