Testicular microlithiasis refers to small calcium deposits within the seminiferous tubules of the testes that are typically detected by ultrasound. While they do not usually cause symptoms, testicular microlithiasis is associated with genetic disorders like Down syndrome and Klinefelter syndrome. Its relationship with male infertility is debated, though it may be linked to worse semen quality. The risk of testicular cancer is higher in men with testicular microlithiasis and infertility or other risk factors, though the risk is low if microlithiasis is the only finding. Biopsy of the testes is controversial in evaluating cancer risk from microlithiasis alone.

1. Testicular Microlithiasis

2. INTRODUCTION
• Testicular microlithiasis corresponds to concretions of hydroxyapatite
surrounded by fibrosis located in the seminiferous tubules.
• The first sonographic identification of Testicular Microlithiasis was
described by Doherty in 1987
• They are due to the insufficient capacity of Sertoli cells to phagocyte
the degenerate cells present in the seminiferous tubules.
• They are commonly discovered by ultrasound (US)

3. INTRODUCTION
• They do not typically affect Leydig cells and the majority of the
uninvolved seminiferous tubules often have abnormal spermatogonia
and reduced luminal diameters.
• Microliths can be seen in the testis as well as in extra testicular
structures such as the lungs and the central nervous system, with
genetic factors also thought to play a role in their development.

4. DEFINITION
• The presence of multiple micro intratubular calcifications without any
acoustic shadow in the testicle and is often an incidental finding in
ultrasound examination of the scrotum.
• The microliths do not bring about pain or symptoms and are
impalpable.
• TM can be either unilateral or bilateral.

5. GRADES
• Three grades are distinguished
according to the number of Testicular
microlithiasis described by
parenchyma per field of view
• Grade 1 (Limited): 5 to 10
• Grade 2 (Classic): 10 to 20
• Grade 3 (Diffuse): with more than 20

6. GRADES
• Significance - A cluster (a few microliths
per field in a cluster) may be more
worrying than TM scattered throughout
the testis. It may indicate a dysgenic area
in the testis, in which carcinoma in situ
(CIS) may develop

7. PREVALENCE
• The prevalence is varied in the past data
• In symptomatic adults, it range between 0.6% and 9.0%
• In health population (adults without symptoms) from 2.4% to 5.6%.
• In a group with genetic disorders, the prevalence of TM has been
reported much more higher.
• In men with Klinefelter syndrome is as high as 17% and 36% in men
with Down syndrome

8. ASSOCIATION WITH DOWNS SYNDROME
• The boys with Down syndrome has higher prevalence of Testicular
microlithiasis than the general healthy population.

9. ASSOCIATION WITH McCUNE-ALBRIGHT SYNDROME
• A congenital disease characterized by
polyostotic fibrous dysplasia, café au- lait
pigmentation and early puberty.
• Two studies were included concerning Testicular
microlithiasis and MAS.
• The prevalence of Testicular microlithiasis in
MAS males was 24.1% - 62.5%.
• One testicular cancer (embryonal cell tumor)
was reported among 62 cases of MAS.

10. Downs and McCune Albright Syndrome
• Both appear to have the highest frequencies of Testicular
microlithiasis, ranging from 23 to 63%
• The present analysis revealed that in these conditions there seemed
to be no relation between Testicular microlithiasis and development
of testicular cancer
• This association between Testicular microlithiasis and chromosomal
abnormalities may indicate Testicular microlithiasis as part of a
degenerative process of the testis.

11. ASSOCIATION WITH INFERTILITY
• TM association with male infertility is debatable
• Incidence of TM in a sub fertile population is up to 20%.
• Reduction in sperm count and sperm motility in a man with microliths is
attributable to TM-related obstruction of seminiferous tubules present in
30 to 60% of patients with TM .
• Inflammation and calcification in the seminiferous tubules area bring about
deterioration in sperm quality and cause sub infertility.
• TM is associated with worse semen parameters in adult men with
infertility.
• TM was reported to be more prevalent in patients with spermatogenic
defects such as severe oligospermia and reduced testicular volume.

12. Association of testicular microlithiasis with Male
Infertility and Tumor
• Testicular microlithiasis and infertility was
associated with an approximated 7 fold
higher cancer risk compared to infertile men
without Testicular microlithiasis
• Testicular microlithiasis may be an indicator
of a “testicular dysgenesis syndrome”
consisting of infertility, cryptorchidism, CIS
and testicular cancer

13. • EUA 2022 - The risk for infertility may be higher in
patients with microlithiasis and if these patients
have any signs of infertility later, the risk of
developing a tumor seems to be higher compared
to patients without microlithiasis and infertility
• In the past, there was concern that testicular
microlithiasis may increase the risk of testis cancer.
However, more recent data indicates that testicular
microlithiasis does not increase the risk of testis
cancer when there is no solid testis mass and no
other risk factors for testis cancer
Association of testicular microlithiasis with Male
Infertility and Tumor
Risk Factors___________________________

14. Association of testicular microlithiasis with
testicular cancer according to EUA and AUA
Testicular microlithiasis
without a concomitant
solid testis mass
Testicular microlithiasis in
men with no solid testis
mass and no risk factors for
testicular cancer
Does not require further
evaluation
Testicular microlithiasis
(but no solid testis mass)
and at least one risk for
testis cancer
Annual follow-up with
Ultrasound is controversial
and monthly self-
examination should be
advised
Role of testicular
biopsy

15. Role of Testicular Biopsy in Patient with TM & RF
• In patients at risk to develop testicular cancer, observation versus
testicular biopsy is debatable.
• At present/ testicular biopsy remains the gold standard to detect
ITGCN
• The early biopsy allows treating early these patients with
radiotherapy therefore avoiding orchiectomy and the risk of
subsequent chemotherapy. However, such an approach could alter
definitively spermatogenesis and has no impact on overall survival.

16. • When biopsy is indicated for fertility purposes in patients with
testicular microlithiasis, a search for ITGCN should be systematically
performed.
• Observation versus testicular biopsy is also debatable in patients
previously treated by orchidectomy for a testicular cancer and
harboring microlithiasis in the contralateral testis
Role of Testicular Biopsy in Patient with TM & RF

17. • Due to the low incidence of a contralateral tumor, even in cases of
testicular microlithiasis, there is no indication for contralateral
testicular biopsy in prepubertal boys (EUA 2022).
• While in adult an individualized approach based on
• Age of the patient
• Presence of concurrent features of testicular dysgenesis syndrome
• Fertility of the couple
• Desire of paternity
• Ultrasound pattern (bilateral and clustered vs unilateral and limited)
Role of Testicular Biopsy in Patient with TM & RF

20. Association of testicular microlithiasis with
testicular cancer
• Testicular microlithiasis with a concomitant solid testis mass - these
patients are assumed to have testis malignancy surgical exploration
with testicular biopsy or orchiectomy should be considered

21. Conclusion
• This association between Testicular microlithiasis and chromosomal
abnormalities may indicate Testicular microlithiasis as part of a
degenerative process of the testis.
• Testicular microlithiasis and infertility was associated with an approximated
sevenfold higher cancer risk compared to infertile men without Testicular
microlithiasis
• In the absence of risk factors, the occurrence of testicular cancer in
patients with Testicular microlithiasis is similar to the risk of the general
population.
• TM at risk to develop testicular cancer, observation versus testicular biopsy
is debatable.
• Most masses in the testicle are assumed to represent testicular cancer until
proven otherwise.

22. Thank you