In the color doppler ultrasonography examination, right testis was in normal sizes and its echo was minimally decreased compared to the left testis. The echo of epididym was decreased and its blood flow was increased. Testicular perfusion in the right was minimally increased. Thickness of the scrotal skin was clearly increased at the right side. On the right side, a mass extending from inguinal channel to the scrotum about 8x7 cm was seen.

There was cystic areas, echogen particles similar hemorrhagic focus and hypoechogen foci resembling inflammated connective tissue. there was a mass extending from right inguinal canal to right hemiscrotum. Radiological diagnosis was as an abscess or hemorrhage (epididymoorchitis?). Testicular tumor’s markers and results of hematological and biochemical analysis were normal. Right orchiectomy was performed.

In macroscopic examination, the mass which was 7 cm in maximum diameter and had focal hemorrhage areas was composed of fibrous and adipose tissue and pushed normal testicular tissue (Figure 1).

Figure 1: Slices of the orshiectomy specimen show paratesticular mass (m) that pushing testis (t) and contain hematoma (h) focuses.

In microscopic examination, the tumor showed disorganized mature tissue that composed of thick-walled vessels, fibrous, muscular and adipose tissue (Figure 2-3).

Figure 2: Seen the paratestiküler mass (m) that contain disorganized soft tissues (t: testis, ta: tunica albuginea) (H&E, x40)

Figure 3: A and B; Paratesticular mass composed of irregular muscle bundles (m), arteries (a) with thick wall, nerves (n) and adiposus tissue (l) (H&E, x100)

Additionally, chronic inflammatory infiltration, foreign body reaction and cholesterol clefts were seen in the disorganized tissue (Figure 4). By these findings, it was diagnosed as paratesticular hamartoma

Figure 4: Postoperative changes: A; hematoma area (H&E, x100), B; inflammation and fibrosis that infiltration between muscle bundles (H&E, x200), C; foreign body reaction and cholesterol clefts (H&E, x200), D; fat necrosis and histiocyte infiltration (H&E, x200)

Tumors of the spermatic cord and paratesticular region are uncommon. The paratesticular area is a complex anatomical area which includes the contents of the spermatic cord, testicular tunics, epididymis and vestigial remnants, such as the appendices epididymidis and testis. Histogenetically, this area is composed of a variety of epithelial, mesothelial and mesenchymal elements. Neoplasms arising from this region therefore form a heterogeneous group of tumors with different behavioural patterns and have a wide differential diagnosis. The clinical presentation is almost always a mass or swelling, which may or may not be painful and is occasionally accompanied by hydrocele. These clinical findings do not help to distinguish a benign tumor from a malignant tumor. Paratesticular tumors can present at any age, which may sometimes give a clue to the histological diagnosis⁸.

Lioe et al.⁸, in 36 years period, reported 85 paratesticular tumors in which 66 (78%) were benign lesions and the remaining 19 were malignant. The most common benign lesion was the adenomatoid tumour. Lipomas are also seen frequently^9,10. Other much rarer benign lesions included leiomyoma, haemangioma, fibroma, neurofibroma and papillary mesothelioma. While lipomas are seen at a large interval of age (2-71 age), adenomatoid tumors are often seen between 20 to 50 ages and rarely seen in childhood. Sizes of these tumors are variable. While adenomatoid tumors are rarely over 10 cm, diameters of lipomas and malignant tumors are usually over 10 cm⁸.

In another study¹¹, twenty two patients with tumours or tumour-like conditions of the paratesticular region were evaluated over a 5 years period. Of these, 16 (73%) were benign with only one true neoplasm (papillary cystadenoma). The tumor-like conditions were comprised of 6 cases of adenomatous hyperplasia of epididymis, 4 cases of spermatic granuloma, 2 cases each of spermatocele and nodular-fibrous proliferation and one mesothelial cyst¹¹.

To date, paratesticular hamartoma cases have been reported in English literature. The first case was reported by Srigley and Hartwick, in a two years old child¹. They described that the tumor consisted of a disorganized cluster of tubules embedded in a loose connective tissue stroma and tubules were lined by cells that were cytologically similar to normal rete testis. This tumor is called as hamartoma of rete testis and is morphologically different from fibrous hamartoma.

Histopathologic features of our case were compatible with fibrous hamartomas described in the literature. On contrary to the literature, in our case, focally dense chronic inflammatory reaction, lymphoid aggregations, foreign body reaction and cholesterol clefts were seen. We believe that the most of these changes are developed secondary to lipid extraction from cells, due to chronic trauma or surgical operation.

The second case is reported in childhood by Jimenes and et al.¹² and was diagnosed as “paratesticular fibrous hamartoma”. However, we could not get information about morphological features of this case. According to these reports, our case is the first paratesticular fibrous hamartoma in adulthood.

Finally in the differantial diagnosis of the paratesticular tumors, paratesticular fibrous hamartomas should have been taken into consideration. These tumors may be confused with malignant tumors of testis and paratesticular region. Preoperative diagnosis of the paratesticular hamartomas prevents unnecessary orchiectomy.