New ultrasound techniques in the assessment of incidental, impalpable, testicular lesions –


can radical orchidectomy be avoided? Franchesca Wotton, Simon Freeman


Scrotal ultrasound is the widely available imaging modality of choice for the assessment of scrotal pathology and remains at the forefront in the diagnosis of testicular cancer.


W


hilst some testicular lesions may display characteristic features on conventional B-mode and colour Doppler ultrasound, many lesions are equivocal. Increasing referral for scrotal ultrasound, for a wide variety of scrotal symptoms, combined with improvements in ultrasound


resolution, have led to the increased, and often incidental, detection of small impalpable indeterminate lesions, posing a management dilemma. The fear of failing to remove a testicular germ cell tumour (TGCT) has historically led to overtreatment with radical orchidectomy being performed for many patients with benign disease. Newer ultrasound techniques offer the ability to further characterise lesions; contrast enhanced ultrasonography (CEUS) enables improved assessment of lesion vascularity; tissue elastography provides assessment of cellularity by measuring the ‘stiffness’ of the lesion. Dynamic contrast-enhanced MRI is also an emerging modality to aid differentiating between benign and malignant testicular lesions. These new imaging techniques could potentially minimise the fertility, endocrine, cosmetic and


psychological issues associated with a radical orchidectomy, particularly in the context of benign disease. The purpose of this review, therefore, is to explore the common appearances of intratesticular lesions and in particular focus on the role of new ultrasound techniques in the further characterisation of incidentally discovered, impalpable lesions. Ultimately, can we manage some cases with interval imaging or testicular- sparing surgery (TSS) rather than radical orchidectomy?


The issue Testicular cancer accounts for 1% of all male cancers in the UK, most commonly affecting young and middle- aged men. B-mode and colour Doppler ultrasound are readily available, non-invasive imaging techniques that are the first-line, and often only, imaging investigation undertaken prior to surgery. Ultrasound is


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extremely sensitive in detecting intratesticular lesions and increasingly many small, impalpable lesions are being detected incidentally during conventional testicular ultrasound, performed to investigate a variety of conditions such as infertility, testicular pain or endocrinological abnormalities where clinical examination does not identify a focal testicular lesion. In a series of 4418 men undergoing scrotal ultrasound for infertility, 1% were found to have a sub-centimetre hypoechioc testicular lesion1


. Until recently radical orchidectomy


has been the mainstay in the management of all malignant and equivocal intratesticular lesions due to the lack of steadfast ultrasound features that can reliable distinguish benign from malignant lesions2 the majority of palpable testicular masses are malignant, approximately 80%3


of incidentally discovered


impalpable testicular masses are benign. Advocating radical orchidectomy, therefore, as the preferred option for all focal testicular lesions, regardless of their size, presentation and sonographic appearances would result in overtreatment for many patients, with the associated implications for fertility, endocrine function and body image. In many cases, imaging surveillance or testicular-sparing surgical techniques are appropriate rather than radical orchidectomy and are being increasingly advocated, particularly in managing incidentally discovered impalpable lesions3


.


Conventional B-mode and colour Doppler ultrasound Palpable, rounded and echopoor testicular masses showing evidence of internal vascularity on Doppler examination should still usually be assumed to represent TGCTs, and in this situation radical orchidectomy will usually be recommended. Certain testicular lesions demonstrate grey-scale features which indicate a benign nature. Epidermoid cysts may demonstrate a characteristic 'onion skin' layered appearance with absent vascularity4 (figure 1).


Simple intratesticular cysts, cystic ectasia of the rete testis and intratesticular varicocoeles can be confidently diagnosed by their ultrasound appearances. Wedge shaped avascular lesions without mass effect are likely to represent areas of testicular infarction and can be managed conservatively with interval ultrasound. Uniformly hyperechoic lesions and lesions arising from the testicular tunica are also usually benign and may also be appropriate for interval ultrasound rather than surgical intervention.


. Although


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