Testicular Microlithiasis (TML) Testicular microlithiasis is a relatively common incidental finding on scrotal ultrasound with a prevalence of approximately 3% in adult males17
. The general definition of TML is the presence of five or more small,
non-shadowing, focal echogenicities within the testis, often occurring bilaterally. The significance and management of TML has been controversial due to the widely documented association of TML with testicular cancer, in particular germ cell tumours18
. This association has led many ultrasound practitioners
to recommend ultrasound surveillance in these patients, although there is no consensus on surveillance intervals, duration or patient selection18
(and no other risk factors for testicular cancer) has been exaggerated and in most patients surveillance ultrasound cannot be justified. New guidance has recently been published, proposing annual ultrasound surveillance only in the presence of additional risk factors such as an atrophic testis, cryptorchidism, a previous history of testicular cancer or family history in a first degree relative19
9. . It is probable that the risk of developing TGCT in patients with TML
quantitative contrast-enhanced US of benign and malignant testicular tumours. Radiology 2014; 273(2): 606-618. 6. Horstman WG, Melson GL, Middleton WD and Andriole GL. T
1992; 185(3): 733-737. 7. Shah A, Lung PF 8. , Clarke JL et al. New ultrasound techniques for imaging of the indeterminate testicular lesion may
avoid surgery completely (letter). Clin Radiol 2010; 65: 496-497. Piscaglia F
, Nolsøe C, Dietrich CF , De Zordo T lesion. Radiology , et al. The EFSUMB Guidelines and recommendations on the clinical practice of
contrast enhanced ultrasound (CEUS): update 2011 on non-hepatic applications. Ultraschall in Med 2012; 33 (1): 33–59. Aigner F
, Pallwein-Prettner L, et al. Real-time tissue sonoelastography for the evaluation of testicular . 2012 May; 263(2):584-589.
10. Goddi A, Sacchi A, Magistretti G, Almolla J, Salvadore M. Real-time tissue elastography for testicular lesion assessment. Eur Radiol. 2012; 22:721-30.
11. Grasso M, Blanco S, Raber M, Nespoli L. Elasto-sonography of the testis: preliminary experience. Arch Ital Urol Androl. 2010 Sep; 82(3):160-163.
. TML as an incidental finding
in a patient with an impalpable testicular lesion is however, a significant finding, increasing the probability of malignancy.
Conclusion Advances in scrotal ultrasonography have led to the more frequent detection of incidental small, impalpable and equivocal intratesticular lesions, which are frequently benign on histology. Historically, suspicious and indeterminate lesions have been managed with a radical orchidectomy with the associated psychosocial, endocrinological, sexual and fertility issues affecting, unnecessarily, a large cohort of patients with benign disease. Newer ultrasound techniques such as CEUS and elastography, when added to conventional B-mode ultrasound in a 'multiparametric' examination, can offer the means of better characterising vascularity and inherent stiffness of these lesions, particularly in the context of confirming benignity. Therefore, we advocate the use of multiparametric scrotal ultrasound for evaluating small, impalpable and indeterminate intratesticular lesions, with the aim of reducing the number of radical orchidectomies performed in these patients. Further evidence with surgical, oncological and radiological consensus is required to establish the future roles of serial ultrasound surveillance and percutaneous biopsy of small impalpable testicular lesions. A multidisciplinary discussion between radiologists, urologists and pathologists, with wider availability of TSS at specialist centres, offers the opportunity for improved outcomes in patients with incidentally discovered impalpable testicular lesions.
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ABOUT THE AUTHORS Dr Franchesca Wotton is a post fellowship Specialist Registrar on the Peninsula Radiology trainee scheme at the Peninsula Radiology Academy, Plymouth. She is about to embark on a fellowship in cardiothoracic radiology.
Dr Simon Freeman is a Consultant Radiologist at Derriford Hospital, Plymouth and has a sub- specialty interest in uroradiology and ultrasound. He is currently the President Elect of the British Medical Ultrasound Society.
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