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Purpose: Combining computed diffusion-weighted imaging (DWI) with readout-segmented echo-planar-imaging may shorten acquisition time and improve imaging quality. This study aimed to compare computed vs. acquired DWI qualitatively and quantitatively in visualizing scrotal or testicular lesions., Materials and Methods: We retrospectively enrolled 57 consecutive men who underwent scrotal MRI. Four computed DWI sets (cDWI 800 , cDWI 1000 , cDWI 1200 , and cDWI 1400 ) were generated from acquired DWI with two lower b-values (150 and 600 s/mm 2 ). Acquired DWI (DWI 800 and DWI 1000 ) and computed DWI were compared through qualitative (susceptibility artifact, signal loss artifact, anatomic clarity, and lesion conspicuity) and quantitative assessment (signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and lesion-to-testicular parenchyma contrast ratio (CR))., Results: Computed DWI was prone to signal loss artifact and slightly lower assessment scores in terms of anatomic clarity and lesion conspicuity, comparing with acquired DWI. The SNR of computed and acquired DWI decreased with increasing b value. Under the same b-values (800 and 1,000 s/mm 2 ), there was no difference in the median SNR and CR between computed and acquired DWI. The median CR of cDWI 1400 was significantly higher than that of the other DWI sets excepting cDWI 1200 (P=1.000). The median CNR tended to be lower for computed vs. acquired DWI, while no significant difference (P=0.233)., Conclusions: Computed and acquired DWI were nearly equivalent in both qualitative and quantitative evaluations at the b values of 800 and 1,000 s/mm 2 . Computed DWI could enhance the contrast of scrotal or testicular lesions., (Copyright © 2024 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aim: To assess the value and efficacy of real-time shear-wave elastography (SWE) of normal testicular parenchyma and various common testicular diseases in clinical practice., Materials and Methods: SWE was undertaken in 338 patients (mean age: 43.2±17.2 years, range 17-78 years) comprising normal testicles (n = 358), testicular microlithiasis (n = 40), and various testicular diseases (n = 208) and the stiffness was recorded. The final diagnosis was correlated with the clinical context, long-term follow-up, or histopathology. Statistical evaluation was performed to provide a stiffness threshold for pathological diagnosis., Results: The mean size of testicular lesions was 2.6±1.5 cm (range: 10-42 mm). The mean Young's modulus value for normal testis was recorded at 4.55±2.54 kPa. Whatever the stage of microlithiasis, a higher statistically significant stiffness value was recorded. For acute orchitis, the mean stiffness value was slightly higher, but not statistically significantly. The testicular tumoural processes presented a median stiffness value of 21.02 kPa with a cut-off of 16.1 kPa. Fibrosis presented the highest median stiffness value of 30.03 kPa with a cut-off of 26.3 kPa. By analysing the distribution of the different pathological groups, the difference was statistically significant between fibrosis and tumoural processes (p = 0.001)., Conclusion: SWE is a feasible technique in the exploration of the testicular parenchyma. SWE values can be used to differentiate testicular fibrosis from a tumoural process with confidence., (Copyright © 2020 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aim: To assess the diagnostic performance of conventional ultrasound (US) and contrast-enhanced ultrasonography (CEUS) in the differential diagnosis of non-palpable intratesticular tumours., Materials and Methods: The local ethics review board approved the protocol, and all of the patients provided written informed consent. Between December 2011 and February 2014, men with non-palpable testicular tumours and normal tumour markers who were referred for surgery were included. The tumours were analysed by conventional US, including B-mode and colour Doppler US (CDUS) as well as by CEUS. Morphological aspects and qualitative and quantitative CEUS criteria, based on visual enhancement and time-intensity curves, were assessed for each lesion., Results: Forty patients were ultimately included. Based on histopathological results, the tumours were classified into three groups: benign tumours (n=16), malignant tumours (n=15), and burned-out tumours (n=9). In B-mode, the morphological aspects were significantly different between benign and malignant tumours (p-values from 0.0002 to 0.008). Qualitative and quantitative analyses of the CEUS images revealed that burned-out tumours exhibited significantly less enhancement than malignant and benign tumours: in burned-out tumours, time-intensity curves were flat, whereas in both benign and malignant tumours the curves had a bell-shaped pattern. All intensity parameters were lower for burned-out tumours compared to benign and malignant tumours (p-value from 0.0001 to 0.026). Both benign and malignant tumours enhanced strongly, however, and no significant difference between the two was noted (p-value from 0.0721 to 0.0953)., Conclusion: Unlike conventional US, which enable benign lesions to be differentiated from malignant or burned-out tumours, CEUS failed to enabled differentiation between benign lesions and malignant vascularised testicular tumours. CEUS appears to have the potential, however, to differentiate burned-out tumours from vascularised testicular tumours., (Copyright © 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Although the majority of men presenting with non-seminomatous germ cell tumours (NSGCT) are cured, late relapse (occurring more than 2 years after obtaining a complete response to treatment) is increasingly recognized. The typical patterns of disease spread have been well-documented, but the findings at late relapse are more variable and less well-described. We discuss the phenomenon of late relapse, the characteristics of teratoma differentiated (TD), and the issue of long-term imaging surveillance of patients with NSGCT. The potential sites of late relapse of NSGCT and the associated spectrum of imaging appearances are illustrated.

An understanding of the embryology of the adrenal glands is necessary to appreciate the location of adrenal ectopic, or rest, tissue which can occur anywhere along the course of gonadal descent. This tissue usually has no clinical significance, but may become hyperplastic in patients with primary or secondary adrenal pathology. In congenital adrenal hyperplasia, hyperplastic rest tissue may present as a soft-tissue mass, particularly in the gonads and retroperitoneum, and may be mistaken for tumour. The adrenal in the neonate is proportionately much larger than in the adult; in renal ectopy or agenesis the ipsilateral adrenal is normally sited and may be mistaken for a kidney because of its size. This review article illustrates the embryology of the adrenal with particular emphasis on the relevance of embryology to pathology.

Aim: To illustrate the imaging features of malignant germ cell tumours complicating undescended testes, emphasizing the importance of recognizing this condition and providing a correct diagnosis to facilitate appropriate management., Methods: The clinical presentation, ultrasonography (US) and computed tomography (CT) features of eight consecutive patients with malignant germ cell tumours of undescended testes were reviewed., Results: CT performed in seven patients showed well-circumscribed soft-tissue masses with inhomogeneous enhancement in all cases. US in four patients showed circumscribed masses with inhomogeneous echogenicity. On pathological examination, there were two cases of embryonal carcinoma and six cases of seminoma. All tumours showed necrosis that correlated to inhomogeneous areas on imaging., Conclusion: The radiologist has an important role as he may be the first physician to suggest the diagnosis.

Aims: To describe a new technique of intra-operative ultrasound-guided needle localization of impalpable intratesticular lesions., Materials and Methods: Three patients with impalpable testicular lesions identified on ultrasound underwent needle localization under ultrasound guidance. The procedure was performed in the operating theatre under general anaesthetic using a 7.5-8 MHz linear array probe and a portable ultrasound machine. Under direct guidance, a 21 G needle was placed through the centre of the lesion allowing resection and immediate frozen section analysis., Results: In two patients malignancy was confirmed and an orchidectomy was performed. In one patient a benign lesion was detected obviating the need for orchidectomy., Conclusion: Patients presenting with impalpable testicular lesions can pose a diagnostic dilemma and orchidectomy is often performed. We describe an ultrasound-guided intra-operative localization technique enabling direct pathological examination so surgical approach can be re-evaluated in the presence of a benign lesion. This is particularly important in the case of a solitary testicle in order to preserve testicular function.

Ultrasound examination is the primary imaging investigation used in initial evaluation of the symptomatic testis. In this review the ultrasound appearances of a range of testicular lesions are demonstrated. Particular attention is given to the subject of testicular microlithiasis and its link with germ-cell neoplasia, and also to the sonographic features of epidermoid cysts that may allow testis-sparing surgery., (Copyright 2000 The Royal College of Radiologists.)

Benign testicular tumours are uncommon but if recognized can enable a conservative approach to surgery to be recommended. This pictorial review demonstrates the variety of sonographic appearances of testicular epidermoid cysts correlating them with pathological findings in 19 lesions, the largest reported imaged series to date. Atchley, J. T. M., Dewbury, K. C. (2000). Clinical Radiology 55, 493-502., (Copyright 2000 The Royal College of Radiologists.)

Aim: To clarify the role of pelvic CT in the imaging of patients with germ cell testicular tumours (GCTT)., Patients and Methods: A retrospective analysis was undertaken of all CT examinations performed on patients with GCTT at a regional oncological centre over a 3-year-period. Patient notes were reviewed and data on histology, tumour marker levels, therapy and clinical course obtained. The review interpretation was combined with the original radiological report and clinical data to arrive at a consensus result., Results: Four hundred and forty-three examinations on 167 patients were included. One hundred and nineteen examinations (27%) demonstrated abdominal and/or pelvic lymph node enlargement. Nodal metastasis was entirely or predominantly ipsilateral in 73/77 examinations from left-sided primary tumours (95%) and 35/42 examinations from right-sided tumours (83%). Pelvic nodal enlargement was identified in 37 examinations from 16 patients. Thirteen of these sixteen patients possessed an identifiable risk factor for pelvic nodal metastasis; the remaining three had unequivocal nodal metastases in the abdomen. Combined abdominopelvic CT increased the effective dose equivalent (EDE) by 2.6 mSv (74%) compared with abdominal examination alone. Three hundred pelvic CT examinations were performed on 117 patients without risk factors for pelvic nodal metastasis. For this cohort the radiation burden from pelvic CT was 0.78 manSv, giving a risk of induction of a single fatal cancer of 3.9%., Conclusion: We advocate pelvic CT only at the time of staging, except in patients with a risk factor for pelvic nodal metastasis. Any unequivocal abdominal lymph node enlargement should be regarded as a risk factor. Implementation of this policy would safely reduce pelvic CT examinations in patients with testicular tumours by nearly 50%, with a consequent reduction in patient radiation exposures and a resource saving.

Epidermoid cysts are uncommon tumours of the testes representing approximately 1% of all testicular tumours. Their importance lies in the fact that they are completely benign and can be treated by local excision, thereby saving the patient an orchidectomy. We describe a case in which the patient had multiple epidermoid cysts involving both testes and faced possible bilateral orchidectomy.

Paratesticular rhabdomyosarcoma is a rare tumour of childhood and early adult life. We report a case in which the paratesticular location and colour Doppler appearances led to confusion with epididymitis.

We present two cases of spontaneous testicular infarction. Although the clinical presentation indicated an acute pathology, the ultrasound examination demonstrated focal, hyporeflective intra-testicular lesions that could not be discriminated from tumour. As a result of the ultrasound examinations, radical orchidectomies were performed and diagnoses of spontaneous testicular infarction proven histologically.

We present the sonographic findings and pathologic correlation in a rare case of cavernous haemangioma of the testis. We conclude that cavernous haemangioma of the testis should be included in the differential diagnosis of hyperechoic intratesticular masses.

Primary carcinoid tumour of the testis is extremely rare. We describe a case of testicular carcinoid, discuss the ultrasound appearances and differential diagnosis.

A case is described in which a patient with bilateral testicular seminomas was found also to have testicular microlithiasis. The ultrasound and pathological features are described.

A prospective study of 1494 new referrals for scrotal ultrasound was performed over a 5 year period. In 610 patients referred with a clear clinical diagnosis of epididymal disease, and no clinical suspicion of malignancy, ultrasound diagnosed unsuspected testicular tumours (seven malignant, one benign) in eight patients. In this series one case was counted as false negative for ultrasound diagnosis of tumour, as tumour was the differential diagnosis and not the primary diagnosis. No other patients diagnosed as having benign disease by ultrasound have subsequently been shown to have malignant disease. Sensitivity and specificity of ultrasound for the diagnosis of testicular malignancy in this series is 98% and 99.8% respectively. It is concluded that all patients with scrotal symptoms should be examined by ultrasound in order to achieve the maximal clinical benefit from the early diagnosis of testicular tumours. The implications of this are discussed.

A case of a 91-year-old gentleman who developed massive scrotal swelling secondary to malignant mesothelioma of the tunica vaginalis testis is presented. Preoperative sonography was performed and the findings and difficulty in establishing the pathological diagnosis are discussed.

The sonographic findings in two cases of testicular lymphoma are presented. Both show hypoechoic striations radiating out from a hypoechoic mediastinum testis. This appearance has not previously been described and may represent infiltration along the lymphatics within the testis.

Patients with a testicular mass are usually investigated by ultrasound and the ultrasound appearances have been correlated with the histology. The authors describe two patients with Leydig cell tumours. The first had bilateral tumours which although histologically typical of Leydig cell tumours, had differing ultrasound appearances, one with a previously unreported hyperechoic appearance. The second patient had an impalpable tumour with similar ultrasound appearances to those previously described. The paper illustrates the difficulty of giving an accurate diagnosis of solid testicular lesions and also shows that the previously described appearance of Leydig cell tumour is not pathognomonic.

A study was undertaken to assess the role of computed tomography (CT) as the sole imaging technique for the staging and surveillance of patients with stage I testicular seminoma. Of the 15 patients studied, five (33%) relapsed. This relapse rate differs from other studies. The reasons for this are discussed.

Since 1980, 51 patients with non-seminomatous testicular germ cell tumours (NSGCT) and normal or equivocal initial computed tomography (CT) imaging have also had lymphography performed. Radiological records of these patients were reviewed to determine the extent to which lymphography (LAG) contributed to patient management. Forty-nine patients were retrospectively confirmed to have normal CT but of these 14 (29%) were considered to have nodal metastatic disease on lymphography. These patients and seven others with marker only evidence of tumour received chemotherapy and all remain disease-free. Six of thirty-six patients relapsed, but the incidence was not significantly higher in patients who did not undergo LAG (2 of 8:25%) than among those whose initial LAG was normal (4 of 28: 14%). All relapsing tumours achieved a complete remission with chemotherapy. We conclude that although LAG may have resulted in earlier treatment for some patients, several may have been overtreated on the basis of radiological abnormalities which did not represent metastatic disease. We believe that the success of salvage chemotherapy means that LAG may be safely abandoned as a staging procedure for NSGCT.

A postal survey has revealed a reduction in the practice of lymphography in several hospitals where body computed tomography (CT) is available. Nowhere in this country has this reduction been quite so marked as in East Anglia, where very few lymphograms are now performed. Some of the factors which may be responsible are assessed; in particular, the introduction of body CT.

Thirty patients with testicular teratomas were examined by computed tomography (CT), lymphangiography and chest X-rays/tomography and the role of each investigation in the staging and management of these tumours is examined. It is suggested that CT should be the primary investigation of the abdomen in patients with testicular teratomas and that the lymphangiogram should be reserved for those cases where CT is technically inadequate or where biochemical markers are raised despite a negative CT scan. In the thorax a conventional chest X-ray should be taken and used for follow-up where possible, but CT scans should be performed in all cases with less than three metastases shown on chest radiography.

The distribution of intra-abdominal nodal involvement was assessed in 145 patients presenting with testicular tumours referred for staging by computed tomography (CT). Of the 55 patients with definite evidence of nodal enlargement on CT, 33 had tumours of the left testicle, and 22 of the right. Nodal involvement was predominant in the left para-aortic chain in all 33 patients with a left testicular lesion and confined to the left in 31 (93%). Amongst the 22 patients with a right-sided lesion, nodal involvement was predominantly right-sided in 19 (86%) and confined to the right side in 15 (68%). In no patient were the contralateral nodes larger than the ipsilateral nodes. In all 15 patients in this series with early nodal involvement (8 left testicle, 7 right), disease appeared confined to the ipsilateral side. Although crossover of disease does occur, it was only seen in patients with more advanced disease and subsequent to ipsilateral nodal involvement. Knowledge of these findings, which correlate well with data from anatomical, surgical and direct lymphographic studies, should assist in the CT interpretation of equivocal nodal enlargement and aid decisions on the optimal interval for CT follow-up during surveillance.

Three hundred and seventeen cases which included 100 normal individuals have been studied for roentgen significance of the thoracic paraspinal line (TPL). The descending thoracic aorta greatly determines the course and configuration of the TPL. In a right-sided aorta, the TPL is seen on the right side as a mirror image of a left-sided TPL. Lateral deviation of the TPL and descending aorta occur as an ageing process. In systemic hypertension where there is an aortic unfolding, the TPL also unfolds and the degree of TPL deviation has a fair degree of linear relationship with the severity and duration of hypertension in young individuals. Most cases of mitral valvular disease show lateral deviation of the TPL and descending aorta. In these cases the enlarged left atrium displaces the descending aorta and hence the posteromedial border of left lung posterolaterally tangential to the vertebral column resulting in deviation of the TPL and aorta. Perioesophageal spread of carcinoma of the oesophagus into the posterior mediastinum is indicated by changes in pleuro-oesophageal interface and TPL. Mediastinal lymphadenopathy in cases of testicular tumours may be detected by discovery of TPL deviation on frontal radiographs of the thoracic spine. In extradural masses such as granulomas, abscesses and metastatic deposits, the TPL shows a localised bulge corresponding to the clinical and myelographic level of spinal compression.

Thirty-three cases with malignant disease due mainly to lymphoma and testicular tumours were evaluated by computerised tomography (CT) scanning on the EMI general purpose scanner. In many cases there were either more lymph nodes demonstrated than on lymphography or more disease shown in bone or the thorax than was suspected. CT scanning is particularly valuable in showing mesenteric, retrosternal, axillary and para-aortic lymph node enlargement. Bone, liver and pulmonary metastases were shown when not demonstrated by other methods as well as showing the extent of recurrence of malignant disease. In testicular tumours metastatic spread to paravertebral soft tissues behind the diaphragm was clearly demonstrated. This cannot be seen on lymphography. CT scanning appears to be the most accurate method to date of showing the extent of malignant disease, particularly in cases of lymphoma and testicular tumours.

CT scans of the lungs, mediastinum and abdomen have been performed in 65 patients with malignant teratoma between August 1977 and June 1978. CT is superior to conventional radiology in detecting pulmonary metastases and mediastinal lymphadenopathy. It is a valuable technique for defining the full extent of para-aortic nodal disease and provides more information than lymphography alone. In this series sequential CT scans have been used to monitor treatment response to detect relapse and to assess operability of demonstrable residual disease.

A comparison has been undertaken between conventional radiographic imaging and computed tomography (CT) in 35 patients with testicular teratoma as part of an audit of our investigative approach to staging and follow-up. The CT examination included alternate cuts from the carina of the trachea to the lung bases as the thoracic assessment as well as the standard examination of the abdomen. Lymphangiography appeared to detect Stage IIa lesions better than did CT; however, CT was able to define the volume of abdominal disease more accurately. During the follow-up of Stage I patients, CT detected progressive disease in the absence of tumour marker elevation. Such progressive disease presented within 4 months in the majority of cases. The selective thoracic CT scanning conferred no advantage over whole-lung tomography, only one additional lesion being detected in 123 examinations. It is recommended that CT should be reserved for examining the area above the renal hila, for cases where lymphangiography is equivocal or positive, and that CT scanning of the abdomen in Stage I patients not receiving therapy should be repeated every 3 months following orchidectomy for the first year, irrespective of clinical status.

The pedal lymphographic findings in 260 patients with testicular tumours are reviewed: 117 patients had a seminoma, 105 had a teratoma and 38 combined tumours. 26 percent of seminomas were associated with a positive lymphogram, corresponding figures being 42 percent for teratomas and 53 percent for combined tumours. The role of the lymphogram is (1) to stage the case so that the extent and form of the treatment can be logically assessed, (2) to plan accurately radiotherapy treatment fields, (3) to observe the results of treatment on serial follow-up films, (4) to detect the recurrence of tumour using "re-fill" lymphography if necessary, (5) to show possible unsuspected metastases involving supraclavicular and mediastinal glands, and (6) to give a prognosis, since a negative lymphogram suggests an excellent chance of survival. Three main types of lymphographic appearances are recognized: nodal, mass replacement and "pseudo-lymphomatous". Nodal deposits are most common. Most positive findings are in the para-aortic chain on the same side as the tumour. Iliac involvement is much less common. Seminomas in this series showed a 96 percent crude three-year survival rate. For teratomas and combined tumours the three-year survival rates were 59 percent and 61 percent respectively, but deaths are uncommon in the lymphographically negative Stage I cases. Bone deposits are rare. Only two were found in this series. We do not perform testicular lymphography, but consider there is a useful role for inferior venacavography when there is poor filling of upper para-aortic nodes at lymphography. The importance of taking follow-up films after the initial examination is stressed.

A technique of soft tissue radiography of the testes is presented. The normal radiological appearances are described, and also the radiological features seen in 75 patients with testicular lesions. Of these, 18 patients had malignant neoplasms and 57 patients had benign conditions. Testicular tumours appeared as very radio-opaque, quite sharply defined shadows. Benign conditions were less radio-opaque and often had ill-defined margins. A diagnostic accuracy of 88% was achieved in differentiating between testicular tumours and benign conditions.

Seventy-eight patients with seminoma and 66 patients with teratoma had computed tomography (CT) of the thorax and abdomen performed as part of initial staging following orchidectomy. Four of 65 (6%) seminoma and 13 of 66 (20%) teratoma patients were upstaged by the addition of CT scanning. No seminoma patients with Stage I disease according to abdominal CT and lymphography had an abnormal thoracic CT scan. Seven of 52 (13%) seminoma and 4 of 21 (19%) teratoma patients who were Stage I according to the CT scan had their staging altered by lymphography. CT was of particular value for defining the exact extent and bulk of metastatic disease prior to and following chemotherapy and radiotherapy, prior to surgical excision of residual disease following chemotherapy, and for investigating potential sites of disease relapse. For all patients with teratoma, we recommend CT of the thorax and abdomen, with bipedal lymphography for those with normal CT scans. For seminoma patients, we suggest lymphography followed by abdominal CT and if either is abnormal, thoracic CT.

A study to assess the role of computed tomography (CT) in the management of testicular seminoma showed that CT was of value in defining the extent of bulky abdominal disease at initial staging. After radiotherapy for Stage IIc disease, relapse by 1 year was common and predominantly extra-abdominal. Mediastinal relapse was detected by CT in the absence of raised serum tumour markers or changes on the chest radiograph. It was concluded that CT should be used at initial staging only to assess the volume of bulk disease shown by lymphangiography, that no benefit seemed to accrue from CT scanning of Stage I and IIa patients and that the follow-up of Stage IIb and IIc patients requires regular CT surveillance in the first year, irrespective of clinical status.