Testis: Tumours and Inflammation - HD

Introduction to Testicular Imaging

This morning is a bit like a rollercoaster
ride before lunch.
I've travel from the pancreas to the slurry gland.
Now we're going down to the testes this morning.

Testicular Tumors and Inflammations

What I'm going to do is focusing on the testicular
tumors and inflammations.
And I'm really just going to take it a very simple approach.
Just look at the rows of contrast and hands ultrasound in two areas.
One is how it help us to confirm whether a lesion is benign or not.
And secondly is to look at the row to see how contrast and he ultrasound can help us
to further characterize the vascularity of any testicular lesions.

And I'm sure we all know and practice ultrasound for testicular scrotal pathologies.
And we know that ultrasound is very effective in imaging the scrotum and picking out abnormalities.
And often ultrasound is the only imaging modality before the patient actually go under the surgeon's knife.
And traditionally, gray scale ultrasound is extremely sensitive in picking up testicular masses,
but it doesn't particularly provide sufficient information to allow for further evaluation
for potential differential histological diagnosis.
When there's uncertainty, the test is gets removed in many cases.

So the two areas that we're going to look at are the tumors and the inflammations this morning.
And under this area, there are several possibilities here.
And in on the ones on the left hand side where the benign pathology is suspected,
the patient may have a conservative management with testicular sparing a surgery
or watchful waiting approach.
Whereas on the malignant side, a more likely a management path pathway would be an ectomy.
And when the ultrasound findings are uncertain or misinterpreted, it may result in unnecessary ectomy.
The fear of failing to remove a testicular gem cell tumor as histo historically led to radical ectomy
with traditional practice of, if in doubt, take it out approached by the surgeons.
But it's important that we know that majority of the instantly picked up and non-powerful testicular tumors,
they're gonna be small and they are more likely going to be benign.

So how can we as radiologists, prevent unnecessary architect me and I think that that is the role
that we have to consider.
I think the first thing to look at these are what are the preoperative features of these two groups.
I think looking at the vascularity is going to be a very promising approach.
And because virtually all malignant lesions are vascular, so if we just look at the vascularity,
we may be able to pick out those malignant lesions.
And conveniently, all the benign lesions seems to be avascular.
And if we again, can prove that a lesion is avascular, it may imply this is a benign process.
So this will then direct us conveniently to the correct treatment pathway for the patient that we encounter.

And traditionally, we have used doppler and doppler have served us in detecting vascularity
in distinguishing between hypovascular lesions and avascular lesions.
But the difficulty we encounter is that if the lesion is small, then we may not be able
to conclusively decide whether a lesion is vascular or not.
And we can already see that contrast and hands ultrasound will have an important role in this
in determining the vascularity.
And to this end, the guideline has been published in the potential recommended use
and applications in testicular ultrasound imaging.
And I think the most fundamental aspect of the guideline and the use of testicular ultrasound
is to determine whether low testicular lesion is vascular or pick out those who show which shows no enhancement,
therefore, potentially identify lesions without malignant potentials.

Examples of Contrast Ultrasound in Vascularity Assessment

So just some examples.
If we look at how contrast ultrasound is used in determining vascularity in a lesion where
on the beam or ultrasound, there may not be any striking apparent difference between the two testes,
one on the left and one on the right.
But on the contrast ultrasound, it shows clearly there is no vascular flow without any doubt
within the right testes confirming a global infarction of the right testes.

And then I think this case highlights the use of contrast and hence ultrasound in assessment
of the vascularity within the testes in the light of any of apparently normal testicular absences
on gray scale ultrasound, you may say that color doppler imaging may identify a lack of flow
within the testes, but clearly contrast and an ultrasound here in this case shows the distinctive
lack of blood flow much more obviously in this case.

Application in Trauma Cases

And the same principle applies to the trauma cases as well.
The essential use of ultrasound in the setting of blunt scrotal trauma is to establish the need
of any operative intervention to salvage testes or also to indicate the need of an ectomy
where there's no viable testicular tissue left.
And the addition of contrast and hand ultrasound will help us to establish any tissue viability
and additional benefit for the surgeons to identify the presence of trauma and direct them
for any surgical interventional approach.

So in this case, this is a young patient who came in with an abnormal looking upper pole of the right testes,
which is enlarged with several areas of low reflectivity at the side of the trauma and surgical exploration
was performed, and the tissue of the upper third of the testes appeared dusky and was removed,
which demonstrate an ischemic area.
This area was excised and the remaining testes was preserved according to the preoperative contrast
ultrasound image, which clearly and demonstrate viable tissues to be saved during the operation.
And three months later, after the surgery, we can see reperfusion of the entire test is again
in the remaining tissues.

So this is again highlighting contrast also in offering an imaging pathway to allow us to assess
the viability or vascularity of test tissues.
And also this can apply in a chronic cases in a post-traumatic hematomas.
It's important that when we encounter any hypo coic lesion, we testes even with a history of trauma,
we have to make sure that this is non ental neo neoplastic lesion in the testes and contrast ultrasound
can help us to identify the lack of absence of any vascularity within the lesion, which we know
is a hallmark of a benign lesion.

Inflammatory Processes

So coming back to inflammatory process in uncomplicated cases of or epidemo oras advanced ultrasound
technology probably offer no significant advantages.
But if the in inflammation is complicated and an abscess is formed, which it can be a common complication
of severe epi otitis, then we can, as we are already seeing the usefulness of contrast enhanced ultrasound
in delineating the multi without vascularity, this can be used to help us to first of all to identify
a an area of infarction or abscess formation at the earlier stage.
And also it'll help us to evaluate the size of the abscess and which can again, direct us in terms of
how this patient is best managed.

So here, over two cases here, the one on the right is a 69-year-old gentleman who came in with what looks
like an area of venous infarction.
And this was confirmed on histological confirmation and contrast also, again showed complete absence
of enhancement within the lesion with a very smooth, well delineate regular border and some rim enhancement
around the venous infarct.
On the left hand side, we have a different case of an 81-year-old gentleman with a left testicular abscess,
and his histology confirms the abscess formation.
And ultrasound, again showed a vascular area with a slightly irregular border and vascular projections
into the into the abscess and some ring ring ring enhancement.
The fact that both pathologies are a va a vascular, it makes it difficult to differentiate absolutely
between venous infarct and abscess in some cases.
But again, the lack of enhancement confirmed that this is likely going to be a non-malignant process
and clinical history correlation to usually lead us to the right diagnosis.

Acute Segmental Infarction

Another inflammatory process is an acute segmental infarction of the testes on the gray scale images,
segmental infarction typically appear on ultrasound as a low reflective area, which can be wed shape,
but can be rounded shape as well.
And when they appear as a rounded shape, hypo coele, the main concern is the differentiation of a segmental
infarc to a rounded poorly vascularized tumor.
And the inability to differentiate this ity to testicular tumor can result in unnecessary orchiectomy
and contrast enhance ultrasound again help us to characterize the segmental infarction showing the morphological
features of a lesion, which can be very different from those of hypovascular tumors.

Acute segmental infarct can present as one or more avascular areas, but these are separated by normal vessels
consistent with some ischemic testicular loles within the infarct.
And what's also interesting is that the spectrum of the appearances can differ depending on the timing
of our imaging from the onset of the testicular pain.
So in the acute phases, acute segmental infarct can present as ischemic lobules seen in the previous case,
but without a peri per regional enhancement.
But in the subsequent subacute phase, the segmental infarc is then characterized by a peri regional re of enhancement,
which then on the follow up or diminished over time and eventually lost with the change of the lesion size and shape.
And recognizing these features allowed us during the follow-up to confirm the differential diagnosis
from other testicular lesions and allow us to take it as a conservative approach with watchful weight.

Focal Lesions and Tumors

On the other end of the spectrum, we want to look at some focal lesions and see how we can further differentiate
them from lesion that requires surgical approach.
I think in the typical lesion, as we say, are the lesion that shows no enhancement.
Epiderm cyst are a good example.
These are usually lesions which is well-defined, and they can have cals fibrin and a very heterogeneous
echo reflectivity and variable B mold appearances.
When there are typical, it's probably easy to make the diagnosis and contrast ultrasound would just add
further confirmation that these are avascular lesions.
But if the BMO appearances are atypical, then contrast and enhance ultrasound would be very useful to confirm
that these are benign avascular lesions compared to this.

When we see a testicular tumor, these are tumors which virtually all of these tumors demonstrate internal enhancement
and the enhancements is usually greater than the surrounding parenchyma.
And what's also interesting is that these vascularity are different from normal vascularity, that there's loss
of normal linear patterns in terms of the vessels within the lesion.
And these features are strongly suggestive of a primary testicular malignancy.
And the features may be observed on doppler ultrasounds, but when a lesion is small contrast enhance ultrasound
will allow us to enhancing these features to be able to detect these features with more confidence.

And compared to the loss of the the pattern of the enhancement is important because they allow us
to differentiate the primary testicular tumor to other forms of mal enhancing malignancies.
For example, there's increasing recognition that the primary testicular lymphoma enhancing a slightly different
pattern to the primary germ cell tumors.
So the on both con color doppler, ultrasound and contrast and enhance ultrasound, primary testicular lymphoma
demonstrates a non branching linear pattern.
Whereas in the seminomas, they demonstrate a pattern where there's a loss of normal linear vascularization
with crisscross pattern of vessels within those lesions.
So the difference in the vascular pattern may allow us to raise the suspicion of hematological origin
of the malignancy.
And once the suspicion is made, clinical correlation with the patient's fi laboratory finding and other histories
may be useful to help us to establish diagnosis of lymphoma.

Gray Areas: Leydig Cell Tumors

So far, everything has worked neatly by using the vascularity to help us to place the patient
in the right area of management.
But there is some gray areas and area where we need to pay further attention to avoid unnecessary ectomy.
And this occurs in the area of late cell tumors.
These tumors are typically vascular.
They have a very low malignant potential and contrast and hands out cell in this area allows us
to further characterize the vascular pattern to allow us to make the correct diagnosis.
And there three talked about already in a malignant cell tumor, the enhancement pattern in a typical lesion is
hypervascular, but it enhances slightly differently from the late cell tumor.

So in the semino, in the seminomas, these lesions enhance rapidly, but the contrast then wash out
and loses the hyper vascularity hyper enhancement compared relative to the surrounding parenchyma.
Whereas what we have noticed increasingly is that these small laic cell tumors one of the distinctive enhancement
feature is that they demonstrate vascular pattern that shows rapid enhancement, but enhancement hyper enhancement
to the surrounding parenchyma is longstanding.
And when you're doing these scans, you'll see these lesion lights up for a long time during your enhancement
face on examination.
And these can be demonstrated on time intensity curves where there's a larger differentiate between these tumors
compared to the surrounding parenchyma.
And study has been looked at different parameters, look at the peak values and time to peak values,
and more importantly, looking at the wash cell pattern of these lesions to demonstrate that there is a differentiation
between the enhancement pattern between these two tumors.

And our observation has also been observed by other groups which show that when the lesion enhances rapidly
and with rapid wash out, then these are more likely to be malignantly malignant lesions where a be whereas a benign
vascular lesion features a long wash out of micro bubbles, which is longer lasting.
And these are useful features to further characterize a vascular testicle lesions when we see them.

Rare Cases: Capillary Hemangioma

Another example of a the ability of contrast and handout sound to characterize lesion further than conventional
DOPP ultrasound is in this interesting case with a rare diagnosis of a capillary hemangioma.
The testes on the colored up ultrasound, we can see a very hypervascular lesion in within the testes.
But contrast enhanced ultrasound provided a more detailed imaging of the intratumoral VA vasculature,
and it has a very temp high temporal resolution where you can observe these lesions real time.
And following admission administration of microbubble contrast at 28 seconds of injection,
we see this global enhancement and gradually filling from the periphery in a pattern similar to hemangiomas
that we see in other parts of the body.
And this lesion again, is an example of how contrast and handout sound is superior and provides more additional
information in vascular characterization.

Advanced Technologies and Real-World Application

So how does contrast ultrasound help us in the real world?
I think there are further advanced technologies that allow us to gather further information and combined
with other technologies such as strain elastography, you'll help us to further characterize the lesion
before a management decision is made.
So a complete preoperative assessment should include all modalities of ultrasound that will provide further information.
This also implies that no single modality is probably sufficient in provide providing a definite diagnosis
for focal testicular lesions.
And these technologies are complimentary to each other.
And when we have a increase certainty preoperatively, what we can do is change our management with testicular
focal lesions.
And we may be able to select patients more accurately for testicular spare surgery, which may be guided
by ultrasound if necessary, because these lesions can be very small and difficult to detect intraoperatively.

Summary

So in summary, I just like to say that the row contrast sound in confirming benign is that it can conclusively
demonstrate a lack of vascularity to confirm a lesion is benign in the real world, and it's very striking
and distinctive.
And it also sh help us to further characterize any vascularized lesion.
And these differ differing enhancement pattern and characteristics may further allow increase our ability
to select patients for testicular space surgeries.
Thank you very much.