Prepubertal Testicular Tumors in Children: Combined Ultrasound and Pathologic Study

Background Prepubertal testicular tumors represent a distinct clinicopathologic spectrum that differs significantly from adult testicular tumors, necessitating age-specific diagnostic strategies to guide management and preserve testicular function. Purpose This study aimed to characterize the ultrasound (US) features of various histological subtypes of prepubertal testicular tumors and correlate these findings with histopathological results to provide diagnostic clues. Materials and Methods This retrospective study analyzed consecutive pediatric patients with pathologically confirmed testicular tumors at our institution between November 2016 and June 2024. All patients underwent preoperative scrotal US evaluating multiple parameters including tumor size, composition (solid, cystic, mixed), echotexture, vascularity, and calcification. Pathological diagnosis served as the reference standard. Lesions were systematically assessed by correlating US features, such as hyperechoic rings and vascular patterns, with corresponding histological sections. Results The cohort included 118 lesions, with a peak incidence within the first 3 years of life. Benign tumors (e.g., teratoma, epidermoid cyst) constituted 71.2% of cases. A cystic or cystic-dominant US pattern demonstrated a high positive predictive value (PPV) of 96.1% for benignity, but low negative predictive value (NPV) of 47.8%. In contrast, solid or solid-dominant masses exhibited a high NPV for malignancy (91.5%) but a low PPV (49.2%), due to the inclusion of benign entities such as mature teratomas, sex cord-stromal tumors, and hemangiomas. Combining this sonographic pattern (solid and solid-dominant) with AFP >300 ng/mL significantly improved diagnostic performance for yolk sac tumors: PPV 94.7% (95% CI: 71.9–99.7%) and NPV 97.0% (95% CI: 90.8–99.2%). Uncommon entities like juvenile granulosa cell tumors exhibited pathognomonic "swiss-cheese" morphology, while Leydig cell tumors demonstrated infiltrative margins attributed to their unique histopathological growth patterns. Rare metastases and rhabdomyosarcomas presented with distinguishing features that, when combined with clinical context, facilitated accurate diagnosis. Conclusion The combination of high-resolution US and pathological analysis provides a powerful diagnostic framework for prepubertal testicular tumors. Specific US patterns correlate with histologic subtypes and malignant potential. This integrated approach is essential for risk stratification, guiding surgical decisions, and preventing the mismanagement of rare tumor types.