Imaging standards for testicular cancer Role in diagnosis and local staging
• Ultrasound (US): for baseline investigation • Magnetic Resonance Imaging (MRI): rarely used; inconclusive, or nondiagnostic US findings • Computerized tomography (CT) scan: for staging • Fluorodeoxyglucose (FDG)-positron emission tomography (PET): for disease recurrence and follow-up of residual masses Scrotal US with grayscale, colour Doppler, and contrast-enhanced ultrasound (CEUS) elastography, while using a high-frequency linear transducer, remains the modality of choice for the evaluation of scrotal pathology. Scrotal US represents the first-line imaging modality for the evaluation of lesions testicular and extratesticular due to its low cost, wide availability, and high diagnostic accuracy. Ultrasonography has greater than 90% sensitivity and specificity for detecting testicular neoplasia in the appropriate clinical setting [3,4]. It can distinguish between intratesticular or extratesticular mass, and differentiate cystic lesions from solid masses with sensitivity close to 100% [5]. US examination should always evaluate the contralateral testis to rule out bilateral, synchronous, albeit rare, tumours that occur in 2% of seminomas [6]. Even in patients with suspicion of metastatic cancer, a scrotal US should be used to identify an active primary tumour or a “burned out” testicular mass, which is typically a small, impalpable scar or calcification. “Multiparametric US improves the characterization of testicular masses and can reduce the number of unnecessary orchidectomies.” Assessment of vascularity is of limited help. In general, it is not correlated with histology and varies with size. In an early study of 28 patients with surgically proven testicular tumours, 95% of lesions greater than 1.5 cm demonstrated increased vascularity, while 86% of lesions less than 1.5 cm were hypovascular [7]. The increased sensitivity of modern ultrasonographic equipment allows nowadays detecting vessels within both benign and malignant nodules of very small size. Some truly avascular lesions do exist, however, and this finding can be useful to lower the probability of malignancy [2]. On US, seminomas generally appear as hypoechoic, homogeneous, well-defined, mono- or multifocal lesions, with rare anechoic areas (fig.1a-1b). Non-seminomatous neoplasms appear as inhomogeneous lesions with mixed structure, calcifications, indefinite limits, and very often with invasion of adjacent structures (fig.2a-2b). Tumours are almost always vascularized (or hypervascularised), although the absence of blood flow does not rule out testicular cancer. Unfortunately, only a limited number of focal testicular lesions present an appearance suggestive enough for a benign histology at grey-scale US, such as in cases of epidermoid cysts with onion-ring appearance, of with intralesional macrocalcifications, or with shell calcifications, all lacking vascularization at colour Doppler interrogation (fig.3a- 3b). Indeed, a high sensitivity of the US corresponds to a limited specificity of the same. Therefore, it is important to try to improve the specificity of the method by: 1. Integrating imaging at the clinic : Take patient characteristics (e.g. age, ethnicity, medical history) into account. Germ cell tumours are prevalent in the young. Lymphomas, metastases, or other relatively rare lesions are more likely in the elderly. Germ cell tumours are rare in African Americans; in these patients, the possibility of uncommon lesions should also be considered (Fig.4). The presence of pain makes acute situations more probable (focal orchitis, segmental infarction, and hematoma after trauma). In case of bilaterality, consider non-neoplastic lesions (only 1 to 2% of tumours are bilateral).
Prof. Pasquale Martino MD, FEBU, President of the Italian Society of Integrated Diagnostics in Urology, Andrology, and Nephrology (SIEUN) University of Bari (IT)
Fig. 3a Epidermoid cyst, 3b histology
Fig. 8 lymphoma - MRI
Testicular cancer is a relatively rare disease, accounting for about 1 to 1.5% of male malignancies and 5% of all urological malignancies. In Western society, the incidence is around 10 new cases per 100,000 individuals per year. Testicular cancer affects young adults with greater incidence, and represents the most common cancer between 15 and 35 years of age. Infections complications in kidney transplant The overwhelming majority of tumours are germ cell in origin. Most cases of testicular cancer are organ confined at diagnosis and have a good overall prognosis [1]. The survival rate has grown to 90% in the last 30 years. The anatomical-pathological classification of the WHO distinguishes testicular neoplasms into two large groups: germline and non-germline neoplasms. Germline neoplasms, derived from germline cells, represent about 95% of all testicular neoplasms which are divided into subgroups. Non-germline neoplasms are rarer. Seminoma is the most common single cell type in adult, yolk sac tumour, and mature teratoma in prepuberal boys. Lymphoma and metastases (10% of cases) are prevalent in the elderly. Non- seminomatous germ cell tumours may present with a single cell type, or have multiple histologic patterns in 40% to 60% of cases. More than 10% of testicular germ cell tumours are seen in patients with cryptorchidism. Sex cord and stromal tumours are typically small, usually discovered incidentally, and benign in about 90% of cases. Mesenchymal tumours of the testis, both benign and malignant, are rare [2]. Along with clinical examination, diagnostic imaging plays an important role in the assessment of testicular and extratesticular lesions (in diagnosis and initial staging); specifically in examining the primary tumour prior to orchiectomy and evaluating for regional and/or distant metastasis. Scrotal ultrasound (US) is increasingly popular as a complement to the urological examination. This resulted in an incidental finding in asymptomatic patients of an increasing number of small non- palpable lesions, which only 30% are malignant.
represents the examination of choice, it does not always provide an accurate characterization of the nature of scrotal mass lesions. A pre-treatment diagnosis of their benign nature based on imaging findings may obviate unnecessary radical orchiectomy [11]. Sometimes scrotal MRI may be validly recommended afterwards if there are inconclusive US findings or if these are inconsistent with the clinical examination in terms of differentiation and characterization between intratesticular and paratesticular lesions (in rare cases of uncertain or indeterminate US findings) and in local staging of testicular malignancies (in- patients planned for testis-sparing surgery) [12-13]. In conclusion, we can state that multiparametric US (in some cases associated with MRI) improves the characterization of testicular masses and can reduce the number of unnecessary orchidectomies. I would like to express my appreciation for my friends Prof. Michele Bertolotto, Dr. Libero Barozzi, Prof. Pietro Pavlica, and Dr. Massimo Valentino who provided some of the images and most importantly, for their support in the realization of this report. References 1. Thomas KL, Jeong D, Montilla-Soler J, Feuerlein S. The role of diagnostic imaging in the primary testicular cancer: initial staging, response assessment and surveillance. Transl Androl Urol 2020;9 (Suppl 1):S3-S13. doi: 10.21037/tau.2019.07.01 2. Atlas of ultrasonography in Urology, Andrology, and
Fig. 4 sarcoidosis
2. Evaluating the vascularity of the lesions: Tumours are almost always vascularized on colour Doppler (with modern US); to consider the possibility of non-neoplastic lesions if the vascularization is absent (fig.5a-5b) 3. Integrate different techniques : colour Doppler is sensitive enough, but not to exclude hypovascular tumour in all cases. The absence of flows must be confirmed with the CEUS (8) (fig. 5a-5b). For many years, magnetic resonance imaging (MRI) has been proposed as an alternative or integrative method for the study of solid scrotal lesions and for their characterization.
Fig. 5a hypovascular seminoma, 5b hypovascular seminoma-CEUS
Nephrology (P. Martino, A.B. Galosi editors) M. Bertolotto et all. Springer 2017; 40:483-492
There are few studies and few case series reporting the results and diagnostic possibilities of MRI compared to US, especially with the use of new methods. In view of the high sensitivity of US in studying the testicles, MRI is rarely necessary. It is suggested in the presence of a discrepancy between US findings and physical examination, inconclusive US findings, in case of diffuse neoplastic infiltration of the testis [9] (fig.6).
3. Marko J, Wolfman DJ, Aubin AL, et al. Testicular Seminoma and Its Mimics: From the Radiologic Pathology Archives. Radiographics 2017;37:1085-98 4. Wilson SR, Greenbaum LD, Goldberg BB. Contrast- enhanced ultrasound: what is the evidence and what are the obstacles? AJR Am J Roentgenol 2009;193:55-60. 5. Coursey Moreno C, Small WC, Camacho JC, et al. Testicular Tumors: What Radiologists Need to Know— Differential Diagnosis, Staging, and Management. RadioGraphics 2017;37:400-15. 6. Sohaib SA, Koh DM, Husband JE. The role of imaging in the diagnosis, staging, and management of testicular cancer. AJR Am J Roentgenol 2008;191:387-95 7. Horstman WG, Middleton WD, Melson GL, Siegel BA (1991) Color Doppler US of the scrotum. Radiographics : a review publication of the Radiological Society of North
This review focuses on the role of imaging in the diagnosis and local staging of testicular cancer.
America, Inc 11 (6):941-957; discussion 958. doi:10.1148/radiographics.11.6.1749858
Testicular cancer usually presents as a palpable and painless mass. In most cases, the tumour manifests itself with the appearance of a hard and indolent lump on a testicle In 10% of cases, it is associated with testicular pain or disorders already ascribable to its metastatic localization. The imaging techniques that are generally used in the diagnosis, staging and follow-up of testicular tumour are:
Fig. 6 choriocarcinoma-MRI
8. Atlas of ultrasonography in Urology, Andrology, and Nephrology (P. Martino, A.B. Galosi editors) L.Barozzi et all. Springer 2017; 38:461-469 9. Spectrum of Extratesticular and Testicular Pathologic Conditions at Scrotal MR ImagingPardeep K. Mittal, MD Ahmed S. Abdalla, MD Argha Chatterjee, MD Deborah A. Baumgarten, MD, MPH Peter A. Harri, MD Jay Patel, MD Courtney C. Moreno, MD Helena Gabriel, MD Frank H. Miller, M RadioGraphics 2018; 38:806–83 10. Real-time tissue elastography for testicular lesion assessment, 1 Andrea Sacchi, Giovanni Magistretti,1 Joan Almolla, and Maurizio Salvadore3, Eur Radiol. 2012; 22(4): 721–730 11. Tsili AC, Bertolotto M, Rocher L, et al. Sonographically indeterminate scrotal masses: how MRI helps in characterization. Diagn Interv Radiol 2018; 24:225–236 12. Tsili AC, Argyropoulou MI, Dolciami M, Ercolani G, Catalano C, Manganaro L: When to ask for an MRI of the scrotum. Andrology. 2021;9: 1395-1409. https://doi. org/10.1111/andr.13032 13. Incidentally detection of non-palpable testicular nodules at scrotal ultrasound: What is new? M. Valentino, M. Bertolotto , P.Martino, L. Barozzi, P. Pavlica. Archivio Italiano di Urologia e Andrologia 2014; 86, 4 Saturday 11 March, 12:32 - 12:46 Joint meeting of ESUP, ESUR and ESUI: From conventional to molecular diagnostics Pink Area, Coral 4
4. Evaluating the consistency of the lesion: Although not all soft nodules are benign, and not all hard nodules are malignant, testicular elastography can help us in the characterization of small testicular nodules (< 1cm). If soft, they are generally benign, having limited role in larger nodules (10). More than the consistency, its variation over time is important (fig.7).
Fig. 7 seminoma elastography
Fig. 1a seminoma, 1b histology
5. Considering unusual pathologies: An example is hyperplasia of adrenal remnants, burned-out tumour. Among the secondary lesions of the testicle we consider lymphoma in the elderly (fig.8), leukaemia (clinically manifest in 10% of patients), and metastasis (i.e. in the prostate, lung, gastrointestinal tumours, melanoma, or kidney).
It can be deduced that imaging has a central role in the assessment of scrotal masses. Although US
Fig. 2a embryonal carcinoma, 2b histology
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February/March 2023
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