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Testicular Tumor Imaging

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A special issue of Cancers (ISSN 2072-6694). This special issue belongs to the section "Cancer Causes, Screening and Diagnosis".

Deadline for manuscript submissions: closed (31 May 2023) | Viewed by 30490

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Prof. Dr. Laurence Rocher

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1. Service de Radiologie, APHP Hôpitaux Paris Saclay, Hôpital Antoine Béclère, 92140 Clamart, France
2. Faculté de Médecine, Université Paris Saclay, 94270 Le Kremlin-Bicêtre, France
3. BIOMAPS, IR4M, UMR8081, 91401 Orsay Cedex, France
Interests: male reproductive system imaging
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Dear Colleagues,

Testicular cancer is the most common malignancy to affect men between the ages of 15 and 49. It is usually suspected in the presence of a swollen testis revealing a palpable intratesticular mass. Scrotal ultrasound confirms the intratesticular tumor, leading the patient to surgery. Ultrasound and its advanced applications play an important role in the characterization of the tumor, because percutaneous biopsy is still not allowed pre-operative to confirm the malignant process.

In many cases, tumoral blood markers are normal. Imaging including body computed tomography helps in staging and follow up, and PET CT aids in evaluation after chemotherapy for seminomatous germ cell tumors. Some presentations are emerging, like the incidental discovery of undetermined nodules at US, especially during infertility screening. The imaging characterization should be certain in order to avoid inappropriate management such as orchiectomy for a benign lesion, or no follow up or surgery for a missed unusual tumoral process.

In a series of manuscripts authored by experts in the field, we plan to focus on increasing the characterization of testicular tumors or tumor-like masses using conventional ultrasound, and to highlight the role of advances in imaging techniques such as elastography, contrast-enhanced ultrasound, and multiparametric MRI. We will also describe the role of body imaging in the extension screening and follow up, including CT and PET CT.

Prof. Dr. Laurence Rocher
Guest Editor

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Keywords

testicular tumor imaging
ultrasound-color-doppler-elastography-computed tomography
testicular MRI
contrast enhanced sonography

Published Papers (9 papers)

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Research

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13 pages, 4073 KiB

Open AccessArticle

How [18F]-FDG-PET/CT Affects Clinical Management of Patients with Germ Cell Tumors in the Real World

by Cecilia Liang, Julia Sekler, Brigitte Gückel, Christina Pfannenberg, Helmut Dittmann, Ferdinand Seith, Bastian Amend, Konstantin Nikolaou and Christian Philipp Reinert

Cancers 2023, 15(14), 3652; https://doi.org/10.3390/cancers15143652 - 17 Jul 2023

Viewed by 1224

Abstract

Objective: The aim of this study was to evaluate the impact of PET/CT on clinical management of patients with germ cell tumors (GCTs) conducted in a real-world setting, including avoidance of invasive procedures, additional diagnostic imaging, and changes in treatment. Methods: Patients with GCTs were prospectively enrolled into a PET/CT registry study between May 2013 and April 2021. Intended patient management prior and after PET/CT was documented using standardized questionnaires. Changes in oncologic staging and clinical management after PET/CT were recorded, including planned treatment and planned additional diagnostics. Results: Forty-three male patients with GCTs were included consecutively in this study. After PET/CT, oncologic staging changed in 22/43 patients (51%), with upstaging in seven cases (16%), downstaging in ten cases (23%), and cancer relapse in five cases (11%). The number of patients with intended curative treatment remained stable, while a considerable change in intended therapeutic intervention was noted after PET/CT, with an increase in planned chemotherapy from three to eleven patients and a decrease in planned surgical resection from eleven to two patients. In addition, PET/CT contributed to preventing patients from intended invasive procedures including biopsy and surgery in 8/43 (19%) cases and from additional diagnostic procedures in 25 (58%) cases. Conclusion: With the use of FDG-PET/CT as a tool to guide patient management in GCTs, we observed a notable impact on clinical staging and a consequent reduction in the need for additional invasive and diagnostic procedures. These findings are expected to be even more consequential in the future as treatment modalities improve and the life expectancy of GCT patients further increases. Key Points: PET/CT considerably influences the clinical stage of GCT patients. PET/CT has remarkable influence on the choice of therapeutic interventions and reduces additional diagnostic procedures. Full article

(This article belongs to the Special Issue Testicular Tumor Imaging)

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16 pages, 2031 KiB

Open AccessArticle

Ultrasound and Magnetic Resonance Imaging of Burned-Out Testicular Tumours: The Diagnostic Keys Based on 48 Cases

by Thomas Desmousseaux, Emmanuel Arama, Florian Maxwell, Sophie Ferlicot, Chahinez Hani, Karim Fizazi, Cédric Lebacle, Yohann Loriot, Meriem Boumerzoug, Julian Cohen, Nada Garrouche and Laurence Rocher

Cancers 2022, 14(16), 4013; https://doi.org/10.3390/cancers14164013 - 19 Aug 2022

Cited by 2 | Viewed by 1490

Abstract

The spontaneous regression of testicular germ-cell tumours is a rare event whose mechanisms have yet to be elucidated. In the majority of published cases, tumour regression is concomitant with the metastatic development of the disease. Residual lesions, often referred to as burned-out testicular tumours (BOTTs), are difficult to diagnose due to the paucity of published data, especially in the field of imaging. The aim of this article is to describe the radiological signs of BOTTs on multimodal ultrasound and multiparametric MRI from a series of 48 patients whose diagnosis was confirmed histologically. The demographic, clinical and laboratory characteristics of the patients are studied, as well as the data of the imaging examinations, including conventional scrotal ultrasound, shear-wave elastography, contrast-enhanced ultrasound (CEUS) and multiparametric MRI. A total of 27 out of 48 patients were referred for investigation of primary testicular lesion following the discovery of retroperitoneal metastases, 18/48 patients were referred because of lesions suspected on an ultrasound that was performed for an infertility work-up, and 3/48 were referred because of scrotal clinical signs. Of these last 21 patients (infertility work-up/scrotal clinical sign), 6 were found to be metastatic on the extension work-up. Of the 48 orchiectomy specimens, tumour involution was complete in 41 cases, and a small active contingent remained in 7 cases, with 6 suspected upon advanced US and MRI. Typically, BOTTs appear on a conventional ultrasound as ill-delineated, hypoechoic and hypovascular nodular areas. Clustered microliths (60.4%) and macrocalcifications (35.4%) were frequent. Shear-wave elastography showed areas of focal induration (13.5 ± 8.4 vs. 2.7 ± 1.2 kPa for normal parenchyma, p < 0.01) in 92.5% of the patients for whom it was performed, and contrast ultrasonography demonstrated hypoperfusion of these lesions. Of the 42 MRIs performed, BOTTs corresponded to nodules on T2-weighted sequences (hyposignal) with significantly increased ADC values compared with healthy parenchyma (2 ± 0.3 versus 1.3 ± 0.3 × 10⁻³ mm²/s, p < 0.01) and an enhancement defect after injection. This enhancement defect overlapped the lesions visible on T2-weighted sequences in most cases. In the case of predominant partial regression, an enhanced portion after contrast injection was visible on MRI in all seven patients of our series, and in six of them a focal diffusion restriction zone was also present. Spontaneously involuted testicular germ-cell tumours have specific radiological signs, and all of the mentioned examinations contribute to this difficult diagnosis, even histologically, because there is no tumour cell left. These signs are similar whether the patient is initially symptomatic metastatic or whether the discovery is fortuitous on the occasion of an infertility work-up, and whatever the seminomatous or non-seminomatous nature of the germ-cell tumour, when this can be determined. The appearance of regressed germ-cell tumours is often trivialized, which can lead to the wrong diagnosis of an extra gonadal germ-cell tumour (in metastatic patients) or of scarring from an acute event such as trauma or infection, which is not recognized or forgotten. In our series, two patients had an unrecognized diagnosis in their history, with local and/or distant recurrence. An improvement in diagnosing burned-out tumours, combining advanced US and MRI, is necessary in order to optimize patient management, with special attention paid to asymptomatic patients, to prompt extension screening and orchiectomy with analysis of the whole testis. This may reveal a persistent viable tumour or lesions of germinal neoplasia in situ, which are precursors of testicular germ-cell tumours. Full article

(This article belongs to the Special Issue Testicular Tumor Imaging)

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13 pages, 570 KiB

Open AccessArticle

The Diagnostic Value of the Added MR Imaging of the Scrotum in the Preoperative Workup of Sonographically Indeterminate Testicular Lesions—A Retrospective Multicenter Analysis

by Susanne Deininger, Lukas Lusuardi, Maximilian Pallauf, Stefan Hecht, Rosemarie Forstner, Matthias Meissnitzer, Florian A. Distler, Eva Erne, Sebastian Graf, Sebastian Lenart, Juliane Putz, Christian Deininger and Peter Törzsök

Cancers 2022, 14(15), 3594; https://doi.org/10.3390/cancers14153594 - 23 Jul 2022

Cited by 1 | Viewed by 1533

Abstract

Background: The purpose of this study was to retrospectively analyze the diagnostic accuracy of magnetic resonance imaging (MRI) examinations of the scrotum in comparison with standard ultrasound (US) and histopathology. Methods: A retrospective multi-center analysis of MRI examinations of the scrotum performed between 06/2008 and 04/2021 was conducted. Results: A total of n = 113 patients were included. A total of 53 histopathologies were available, with 52.8% malignant and 50.9% benign findings. Related to histopathology, imaging was true negative, false negative, false positive, and true positive in 4.1%, 2.1%, 25.0% and 37.5% for standard ultrasound (US) and 9.1%, 1.8%, 25.5% and 43.6% for MRI. Sensitivity, specificity, positive predictive value and negative predictive value were 94.7%, 20.0%, 36.0% and 88.9% for US and 85.7%, 72.8%, 52.1% and 93.7% for MRI, respectively. Benign lesions were significantly smaller than malignant ones in standard US (p = 0.001), histopathology (p = 0.001) and MRI (p = 0.004). The size of malignant tumors did not differ significantly between histopathology and standard US (0.72) and between histopathology and MRI (p = 0.88). Conclusions: MRI shows good sensitivity and specificity for the estimation of testicular tumors in this collective. Benign lesions are significantly smaller than malignant ones. Both MRI and US can estimate the size of malignant tumors adequately. Full article

(This article belongs to the Special Issue Testicular Tumor Imaging)

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Review

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20 pages, 5803 KiB

Open AccessReview

The Role of CT in the Staging and Follow-Up of Testicular Tumors: Baseline, Recurrence and Pitfalls

by Thibaut Pierre, Fatine Selhane, Elise Zareski, Camilo Garcia, Karim Fizazi, Yohann Loriot, Anna Patrikidou, Natacha Naoun, Alice Bernard-Tessier, Hervé Baumert, Cédric Lebacle, Pierre Blanchard, Laurence Rocher and Corinne Balleyguier

Cancers 2022, 14(16), 3965; https://doi.org/10.3390/cancers14163965 - 17 Aug 2022

Cited by 5 | Viewed by 4111

Abstract

Ultrasound imaging of the testis represents the standard-of-care initial imaging for the diagnosis of TGCT, whereas computed tomography (CT) plays an integral role in the initial accurate disease staging (organ-confined, regional lymph nodes, or sites of distant metastases), in monitoring the response to therapy in patients who initially present with non-confined disease, in planning surgical approaches for residual masses, in conducting follow-up surveillance and in determining the extent of recurrence in patients who relapse after treatment completion. CT imaging has also an important place in diagnosing complications of treatments. The aims of this article are to review these different roles of CT in primary TGCT and focus on different pitfalls that radiologists need to be aware of. Full article

(This article belongs to the Special Issue Testicular Tumor Imaging)

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24 pages, 5134 KiB

Open AccessReview

An Overview of the Role of Multiparametric MRI in the Investigation of Testicular Tumors

by Athina C. Tsili, Nikolaos Sofikitis, Ourania Pappa, Christina K. Bougia and Maria I. Argyropoulou

Cancers 2022, 14(16), 3912; https://doi.org/10.3390/cancers14163912 - 13 Aug 2022

Cited by 4 | Viewed by 5569

Abstract

Conventional ultrasonography represents the mainstay of testis imaging. In cases in which ultrasonography is inconclusive, scrotal MRI using a multiparametric protocol may be used as a useful problem-solving tool. MRI of the scrotum is primarily recommended for differentiating between benign and malignant testicular masses when sonographic findings are ambiguous. This technique is also accurate in the preoperative local staging of testicular tumors and, therefore, is recommended in patients scheduled for testis-sparing surgery. In addition, MRI may provide valuable information regarding the histological characterization of testicular germ-cell tumors, in selected cases. Scrotal MRI may also help in the differentiation between testicular germ-cell neoplasms and non-germ-cell neoplasms. Axial T1-weighted imaging, axial and coronal T2-weighted imaging, axial diffusion-weighted imaging, and coronal subtracted dynamic contrast-enhanced imaging are the minimum requirements for scrotal MRI. A variety of MRI techniques—including diffusion tensor imaging, magnetization transfer imaging, proton MR spectroscopy, volumetric apparent diffusion coefficient histogram analysis, and MRI-based radiomics—are being investigated for testicular mass characterization, providing valuable supplementary diagnostic information. In the present review, we aim to discuss clinical indications for scrotal MRI in cases of testicular tumors, along with MRI findings of common testicular malignancies. Full article

(This article belongs to the Special Issue Testicular Tumor Imaging)

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21 pages, 7840 KiB

Open AccessReview

Testicular Germ Cell Tumours—The Role of Conventional Ultrasound

by Jane Belfield and Charlotte Findlay-Line

Cancers 2022, 14(16), 3882; https://doi.org/10.3390/cancers14163882 - 11 Aug 2022

Cited by 5 | Viewed by 6300

Abstract

Testicular tumours are the most common tumours found in young males and germ cell tumours account for 95% of testicular tumours. Ultrasound is the first-line radiological investigation for imaging of the testis. This article outlines how to undertake an ultrasound examination, including optimal patient position, scanning technique and imaging parameters. Classification of germ cell tumours is provided, and salient imaging features of different tumours are described. Difficulties and pitfalls of ultrasound are described, including tumours found after a trauma presentation, orchitis causing diagnostic difficulties and imaging of small testicular lesions. Other uses of ultrasound are outlined, including looking for a primary testicular tumour following the discovery of retroperitoneal lymph nodes, imaging when tumour-makers increase, local recurrence in the scrotum, and for solid organ biopsy in metastatic disease. Conclusion: Ultrasound remains the first-line of investigation for imaging of the testis, and conventional ultrasound still plays a large role in imaging. On ultrasound alone, accurate morphological characterisation of tumours remains a challenge, despite the imaging features that can be seen in different tumour types. Therefore, histology following orchidectomy of a germ cell tumour remains the gold standard for accurate tumour characterisation. Full article

(This article belongs to the Special Issue Testicular Tumor Imaging)

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15 pages, 3511 KiB

Open AccessFeature PaperReview

Leydig Cell Tumors of the Testis: An Update of the Imaging Characteristics of a Not So Rare Lesion

by Florian Maxwell, Alexia Savignac, Omar Bekdache, Sandra Calvez, Cédric Lebacle, Emmanuel Arama, Nada Garrouche and Laurence Rocher

Cancers 2022, 14(15), 3652; https://doi.org/10.3390/cancers14153652 - 27 Jul 2022

Cited by 4 | Viewed by 2548

Abstract

Pre-operative testicular tumor characterization is a challenge for radiologists and urologists. New data concerning imaging approaches or immunochemistry markers improve the management of patients presenting with a testicular tumor, sometimes avoiding radical orchiectomy. In the past 20 years, imaging modalities, especially ultrasound (US) and magnetic resonance imaging (MRI), improved, allowing for great progress in lesion characterization. Leydig cell tumors (LCT) are rare testicular tumors developing from the stromal tissue, with relatively scarce literature, as most of the studies focus on the much more frequent germ cell tumors. However, with the increase in testicular sonography numbers, the incidence of LCT appears much higher than expected, with some studies reporting up to 22% of small testicular nodules. Multimodal ultrasound using Doppler, Elastography, or injection of contrast media can provide crucial arguments to differentiate LCT from germ cell tumors. Multiparametric MRI is a second intention exam, but it allows for extraction of quantifiable data to assess the diagnosis of LCT. The aims of this article are to review the latest data regarding LCT imaging features, using multimodal ultrasound and multiparametric MRI, and to focus on the peculiar aspect of the testis of patients with Klinefelter’s syndrome. The possibility of an LCT should be raised in front of a small hypoechoic tumor with a marked corbelling hypervascularization in an otherwise normal testicular pulp. Ultrasonographic modules, such as ultrasensitive Doppler, contrast-enhanced ultrasonography, or elastography, can be used to reinforce the suspicion of LCT. MRI provides objective data regarding vascularization and enhancement kinetics. Full article

(This article belongs to the Special Issue Testicular Tumor Imaging)

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20 pages, 11013 KiB

Open AccessReview

Imaging of Pediatric Testicular and Para-Testicular Tumors: A Pictural Review

by Anne-Laure Hermann, Aurore L’Herminé-Coulomb, Sabine Irtan, Georges Audry, Liesbeth Cardoen, Hervé J. Brisse, Saskia Vande Perre and Hubert Ducou Le Pointe

Cancers 2022, 14(13), 3180; https://doi.org/10.3390/cancers14133180 - 29 Jun 2022

Cited by 6 | Viewed by 5142

Abstract

Pre- and post-pubertal testicular tumors are two distinct entities in terms of epidemiology, diagnosis and treatment. Most pre-pubertal tumors are benign; the most frequent are teratomas, and the most common malignant tumors are yolk-sac tumors. Post-pubertal tumors are similar to those found in adults and are more likely to be malignant. Imaging plays a pivotal role in the diagnosis, staging and follow-up. The appearance on ultrasonography (US) is especially helpful to differentiate benign lesions that could be candidates for testis-sparing surgery from malignant ones that require radical orchidectomy. Some specific imaging patterns are described for benign lesions: epidermoid cysts, mature cystic teratomas and Leydig-cell tumors. Benign tumors tend to be well-circumscribed, with decreased Doppler flow on US, but malignancy should be suspected when US shows an inhomogeneous, not-well-described lesion with internal blood flow. Imaging features should always be interpreted in combination with clinical and biological data including serum levels of tumor markers and even intra-operative frozen sections in case of conservative surgery to raise any concerns of malignity. This review provides an overview of imaging features of the most frequent testicular and para-testicular tumor types in children and the value of imaging in disease staging and monitoring children with testicular tumors or risk factors for testicular tumors. Full article

(This article belongs to the Special Issue Testicular Tumor Imaging)

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Other

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21 pages, 2181 KiB

Open AccessSystematic Review

Sonoelastography for Testicular Tumor Identification: A Systematic Review and Meta-Analysis of Diagnostic Test Accuracy

by Derek Ka-Hei Lai, Ethan Shiu-Wang Cheng, Ye-Jiao Mao, Yi Zheng, Ke-Yu Yao, Ming Ni, Ying-Qi Zhang, Duo Wai-Chi Wong and James Chung-Wai Cheung

Cancers 2023, 15(15), 3770; https://doi.org/10.3390/cancers15153770 - 25 Jul 2023

Cited by 2 | Viewed by 1300

Abstract

The objective of this review was to summarize the applications of sonoelastography in testicular tumor identification and inquire about their test performances. Two authors independently searched English journal articles and full conference papers from CINAHL, Embase, IEEE Xplore^®, PubMed, Scopus, and Web of Science from inception and organized them into a PIRO (patient, index test, reference test, outcome) framework. Eleven studies (n = 11) were eligible for data synthesis, nine of which (n = 9) utilized strain elastography and two (n = 2) employed shear-wave elastography. Meta-analyses were performed on the distinction between neoplasm (tumor) and non-neoplasm (non-tumor) from four study arms and between malignancy and benignity from seven study arms. The pooled sensitivity of classifying malignancy and benignity was 86.0% (95%CI, 79.7% to 90.6%). There was substantial heterogeneity in the classification of neoplasm and non-neoplasm and in the specificity of classifying malignancy and benignity, which could not be addressed by the subgroup analysis of sonoelastography techniques. Heterogeneity might be associated with the high risk of bias and applicability concern, including a wide spectrum of testicular pathologies and verification bias in the reference tests. Key technical obstacles in the index test were manual compression in strain elastography, qualitative observation of non-standardized color codes, and locating the Regions of Interest (ROI), in addition to decisions in feature extractions. Future research may focus on multiparametric sonoelastography using deep learning models and ensemble learning. A decision model on the benefits–risks of surgical exploration (reference test) could also be developed to direct the test-and-treat strategy for testicular tumors. Full article

(This article belongs to the Special Issue Testicular Tumor Imaging)

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