Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
47 yo with47 yo with
progressiveprogressive
abdominal painabdominal pain
for 1 monthfor 1 month
Radiology 2004;231:388-392
25 y/o with mass
on imaging
Imaging of the ScrotumImaging of the Scrotum
and Testesand Testes
Jud Gash, MDJud Gash, MD
OutlineOutline
 AnatomyAnatomy
 ImagingImaging
 Testicular MassesTesticular Masses
 Testicular TorsionTesticular Torsi...
AnatomyAnatomy
Scrotum - AnatomyScrotum - Anatomy
 ScrotumScrotum
 layers of fascia, muscle andlayers of fascia, muscle and
connective ...
Testes –Testes –
Embryology andEmbryology and
AnatomyAnatomy
 TestesTestes
– 2X3X5 cm2X3X5 cm
– mediastinummediastinum
 ...
Testes - HistologyTestes - Histology
 Connective tissueConnective tissue frameworkframework
– tunica albugineatunica albu...
Imaging ModalitiesImaging Modalities
 UltrasoundUltrasound
 Modality of choiceModality of choice
– 99% sensitive99% sens...
Imaging ModalitiesImaging Modalities
 MRIMRI
 problem solverproblem solver
 when US inconclusivewhen US inconclusive
 ...
Imaging ModalitiesImaging Modalities
 CTCT
 used for staging of testicular cancer and forused for staging of testicular ...
MassesMasses
 Key: intra vs extratesticular; solid vs cystKey: intra vs extratesticular; solid vs cyst
 IntratesticularI...
Testicular CancerTesticular Cancer
 #1 cancer killer of young men#1 cancer killer of young men
 peak age 20 -45; 90% whi...
Testicular CancerTesticular Cancer
 ClassificationClassification
– Germ Cell (90%) - MalignantGerm Cell (90%) - Malignant...
Testicular Cancer - GCTTesticular Cancer - GCT
 SpreadSpread
– LymphaticLymphatic
 follows veinsfollows veins
 1st eche...
Testicular Cancer - GCTTesticular Cancer - GCT
 StagingStaging
– TNMTNM
– PracticalPractical
 low stagelow stage
– testi...
Testicular Cancer - GCTTesticular Cancer - GCT
 Tumor markersTumor markers
 alpha-fetoprotein, human chorionicalpha-feto...
Testicular Cancer -Testicular Cancer -
ImagingImaging
 UltrasoundUltrasound
 hypoechoic masshypoechoic mass
 heterogene...
SeminomaSeminoma
 Most common GCTMost common GCT
 slightly older ageslightly older age
– does not occurdoes not occur
be...
SeminomaSeminoma
 30 yo with painless30 yo with painless
massmass
Large seminomaLarge seminoma
Multifocal SeminomaMultifocal Seminoma
Embryonal carcinomaEmbryonal carcinoma
 In 90% of mixedIn 90% of mixed
GCT, rarely inGCT, rarely in
pure formpure form
 ...
Yolk Sac TumorYolk Sac Tumor
(endodermal sinus(endodermal sinus
tumor)tumor)
 80% of pediatric80% of pediatric
testicular...
TeratomaTeratoma
 #2 tumor in kids#2 tumor in kids
 common in mixed GCTcommon in mixed GCT
in adultsin adults
 tend to ...
ChoriocarcinomaChoriocarcinoma
 Rare but mostRare but most
aggressive GCTaggressive GCT
 EarlyEarly
hematogeneoushematog...
Mixed Germ Cell TumorMixed Germ Cell Tumor
 More common thanMore common than
any other testicularany other testicular
tum...
““burned out” Germ Cellburned out” Germ Cell
TumorTumor
 Phenomenon of patientPhenomenon of patient
presents with widespr...
CryptorchidismCryptorchidism
 6% of full term neonates; 1% at one6% of full term neonates; 1% at one
year; 10% bilateraly...
CryptorchidismCryptorchidism
 Clinical Problem: nonpalpableClinical Problem: nonpalpable
testistestis
– DDX: cryptorchidi...
Retractile TestisRetractile Testis
 (Hyper)active cremasteric reflex, prompted(Hyper)active cremasteric reflex, prompted
...
MicrolithiasisMicrolithiasis
 Uncommon (.5%)Uncommon (.5%)
 increased associationsincreased associations
 cryptorchidis...
MicrolithiasisMicrolithiasis
 US diagnosisUS diagnosis
 5 or more5 or more
calcificationcalcification
 may be bl andmay...
Non-Germ cell tumorsNon-Germ cell tumors
 5% of testicular cancer5% of testicular cancer
 higher in pedshigher in peds
...
LymphomaLymphoma
 5% of testicular tumor5% of testicular tumor
 #1 in over 50 y/o#1 in over 50 y/o
 only 1% of lymphoma...
Leukemia and MetsLeukemia and Mets
 Common site of recurrenceCommon site of recurrence
 primary disease uncommon herepri...
Tumor-like lesionsTumor-like lesions
 ““intratesticular mass is cancer untilintratesticular mass is cancer until
proven o...
Tumor-like lesionsTumor-like lesions
 DDX:DDX:
 orchitisorchitis
 Hematoma/contusionHematoma/contusion
 infarctinfarct...
Sperm Extraction*Sperm Extraction*
 Sperm extraction forSperm extraction for
infertility are becominginfertility are beco...
Intra-testicular CystsIntra-testicular Cysts
 OverviewOverview
 Tunica Albuginea cystsTunica Albuginea cysts
 Simple cy...
Tunica Albuginea CystTunica Albuginea Cyst
 ?etiology?etiology
 Middle ageMiddle age
 Key to diagnosisKey to diagnosis
...
Simple CystSimple Cyst
 Usually >40 yoUsually >40 yo
 2mm to 2cm2mm to 2cm
 single or multiplesingle or multiple
 Usua...
EpidermoidEpidermoid
 Keratonizing squamousKeratonizing squamous
epithelium filled withepithelium filled with
cheesy lami...
EpidermoidEpidermoid
 Unable to totallyUnable to totally
exclude solid lesionexclude solid lesion
usually andusually and
...
Cystic Transformation ofCystic Transformation of
the Rete Testisthe Rete Testis
 Due to obstruction of efferentDue to obs...
Intra-testicularIntra-testicular
SpermatoceleSpermatocele
 Near mediastinumNear mediastinum
 cystic, can becystic, can b...
Intras-testicularIntras-testicular
VaricoceleVaricocele
 ?etiology. ??etiology. ?
significancesignificance
 May cause pa...
Testicular TorsionTesticular Torsion
 Most common in adolescentsMost common in adolescents
 Acute scrotumAcute scrotum
...
Testicular TorsionTesticular Torsion
 FindingsFindings
 Early, testis is normal; laterEarly, testis is normal; later
bec...
Torsion of AppendigesTorsion of Appendiges
Torsed appendix testis
Scrotal TraumaScrotal Trauma
 2 Categories2 Categories
 penetrating (surgery)penetrating (surgery)
 blunt (imaging)blun...
Scrotal TraumaScrotal Trauma
 UltrasoundUltrasound
 Normal - excludes seriousNormal - excludes serious
injuryinjury
 he...
Scrotal TraumaScrotal Trauma
 MRIMRI
– May play future roleMay play future role
in detection ofin detection of
disruption...
Scrotal Trauma:Scrotal Trauma: extremeextreme
mountain bikersmountain bikers..
Krauscher F Radiology 2001May;219(2):427-31...
Inflammatory DiseaseInflammatory Disease
 Epididymitis/orchitisEpididymitis/orchitis
 usually retrotrade infection from ...
Inflammatory DiseaseInflammatory Disease
 Ultrasound FindingsUltrasound Findings
– involves epididymisinvolves epididymis...
Inflammatory DiseaseInflammatory Disease
 MRIMRI
 edema andedema and
inflammation oninflammation on
T2WT2W
 increasedin...
Orchitis with InfarctionOrchitis with Infarction
 58 yo with scrotal58 yo with scrotal
pain and swellingpain and swelling...
ExtratesticularExtratesticular
PathologyPathology
 Normal Extratesticular VariantsNormal Extratesticular Variants
 Sperm...
Extratesticular VariantsExtratesticular Variants
 Appendix of theAppendix of the
epididymisepididymis
 Isoechoic to epid...
Spermatocele andSpermatocele and
epididymal cystepididymal cyst
 very commonvery common
 usually within/near head ofusua...
Sperm GranulomaSperm Granuloma
 Sperm extravasationSperm extravasation
can result in granulomacan result in granuloma
for...
VaricoceleVaricocele
 Dilated intrascrotal veinsDilated intrascrotal veins
 incompetent valvesincompetent valves
in test...
Hydrocele (hematoceleHydrocele (hematocele
& pyocele& pyocele
 Fluid w/I tunica vaginalisFluid w/I tunica vaginalis
 Hyd...
HerniaHernia
 Via patentVia patent
processus vaginalisprocessus vaginalis
 complex masscomplex mass
 look for peristals...
Extratesticular tumorExtratesticular tumor
 Rare, mostly benignRare, mostly benign
 Adenomatoid tumorAdenomatoid tumor
...
ReviewReview
 Solid massSolid mass
– GCTGCT
 SeminomaSeminoma
 Non-seminomaNon-seminoma
– Embryonal, yolk sac, teratoma...
Upcoming SlideShare
Loading in …5
×

Imaging of the scrotum

8,234 views

Published on

Published in: Health & Medicine, Technology
  • Be the first to comment

Imaging of the scrotum

  1. 1. 47 yo with47 yo with progressiveprogressive abdominal painabdominal pain for 1 monthfor 1 month Radiology 2004;231:388-392
  2. 2. 25 y/o with mass on imaging
  3. 3. Imaging of the ScrotumImaging of the Scrotum and Testesand Testes Jud Gash, MDJud Gash, MD
  4. 4. OutlineOutline  AnatomyAnatomy  ImagingImaging  Testicular MassesTesticular Masses  Testicular TorsionTesticular Torsion  Scrotal TraumaScrotal Trauma  Inflammatory DiseaseInflammatory Disease  Extratesticular PathologyExtratesticular Pathology  MiscellaneousMiscellaneous
  5. 5. AnatomyAnatomy
  6. 6. Scrotum - AnatomyScrotum - Anatomy  ScrotumScrotum  layers of fascia, muscle andlayers of fascia, muscle and connective tissueconnective tissue  Tunica VaginalisTunica Vaginalis – visceral and parietal layersvisceral and parietal layers – potential space around thepotential space around the testestestes  Tunica AlbugineaTunica Albuginea – thick layer of fascia investingthick layer of fascia investing the testesthe testes – Along the posterior surface ofAlong the posterior surface of the testis, the tunica albugineathe testis, the tunica albuginea thickens to form thethickens to form the mediastinummediastinum – The mediastinum projectsThe mediastinum projects inward into the testisinward into the testis
  7. 7. Testes –Testes – Embryology andEmbryology and AnatomyAnatomy  TestesTestes – 2X3X5 cm2X3X5 cm – mediastinummediastinum  contain rete testis - spermcontain rete testis - sperm containing channelscontaining channels – Appendix of testesAppendix of testes  Mullerian duct remnantMullerian duct remnant  EpididymisEpididymis  Attatched to posterolateral testisAttatched to posterolateral testis  head, body and tailhead, body and tail  Appendix of the head and tailAppendix of the head and tail  paradidymisparadidymis  Spermatic cordSpermatic cord  vas, artery, veins and lymphaticsvas, artery, veins and lymphatics  Note: testicular lymphatics drainNote: testicular lymphatics drain to paraaortic; while scrotum toto paraaortic; while scrotum to inguinalinguinal
  8. 8. Testes - HistologyTestes - Histology  Connective tissueConnective tissue frameworkframework – tunica albugineatunica albuginea – mediastinum testismediastinum testis – septa which divide the organ into lobules.septa which divide the organ into lobules.  Within theWithin the lobulelobules, the seminiferouss, the seminiferous tubules produce sperm. Thetubules produce sperm. The seminiferous tubulesseminiferous tubules consist of germconsist of germ cells and Sertoli cells.cells and Sertoli cells. – Germ cells (spermatogonia,Germ cells (spermatogonia, spermatocytes, etc) -spermatocytes, etc) - develop into spermatozoadevelop into spermatozoa – sertoli cells - supporting cellssertoli cells - supporting cells  Between the tubules, theBetween the tubules, the interstitialinterstitial tissuetissue includes connective tissue cellsincludes connective tissue cells and fibers, vessels, and Leydig cellsand fibers, vessels, and Leydig cells – Leydig cells -Leydig cells - produceproduce testosterone.testosterone.
  9. 9. Imaging ModalitiesImaging Modalities  UltrasoundUltrasound  Modality of choiceModality of choice – 99% sensitive99% sensitive – 98% accurate at98% accurate at intratesticular vsintratesticular vs extratesticularextratesticular  techniquetechnique – support scrotum onsupport scrotum on toweltowel – highest MHzhighest MHz transducer (8 or 15)transducer (8 or 15) – color and dopplercolor and doppler – Do normal side first ifDo normal side first if painpain  NormalNormal – homogeneoushomogeneous – bright mediastinumbright mediastinum – TransmediastinalTransmediastinal artery or appendixartery or appendix testistestis
  10. 10. Imaging ModalitiesImaging Modalities  MRIMRI  problem solverproblem solver  when US inconclusivewhen US inconclusive  cryptorchidismcryptorchidism  TechniqueTechnique  support scrotum with warmsupport scrotum with warm towelstowels  surface coil; small fovsurface coil; small fov  T1W and FSET2W (SSFSE),T1W and FSET2W (SSFSE), several planesseveral planes  3mm3mm  Gd?Gd?  Screen abd/pelvis for nodesScreen abd/pelvis for nodes  NormalNormal  homogeneous, intermediatehomogeneous, intermediate on T1W and bright on T2Won T1W and bright on T2W  tunica albiginea andtunica albiginea and mediastinum darkmediastinum dark
  11. 11. Imaging ModalitiesImaging Modalities  CTCT  used for staging of testicular cancer and forused for staging of testicular cancer and for inguinal hernias and infection (Fourniersinguinal hernias and infection (Fourniers gangrene)gangrene)  Nuclear MedicineNuclear Medicine  ?PET/CT?PET/CT
  12. 12. MassesMasses  Key: intra vs extratesticular; solid vs cystKey: intra vs extratesticular; solid vs cyst  IntratesticularIntratesticular  solid - most malignant and germ cell originsolid - most malignant and germ cell origin  mimics/tumor like lesions - infarcts,mimics/tumor like lesions - infarcts, orchitis/abscess and hematomaorchitis/abscess and hematoma – Orchiectomy for benign disease will occurOrchiectomy for benign disease will occur  cystcyst  ExtratesticularExtratesticular  solid - most are benignsolid - most are benign  CysticCystic  CalcificationsCalcifications
  13. 13. Testicular CancerTesticular Cancer  #1 cancer killer of young men#1 cancer killer of young men  peak age 20 -45; 90% whitepeak age 20 -45; 90% white – Incidence of GCT increased inIncidence of GCT increased in cryptorchidismcryptorchidism  PresentationPresentation – painless mass, mild pain or heavinesspainless mass, mild pain or heaviness – 10% present with acute scrotum10% present with acute scrotum  US study of choiceUS study of choice  95% survival rate95% survival rate
  14. 14. Testicular CancerTesticular Cancer  ClassificationClassification – Germ Cell (90%) - MalignantGerm Cell (90%) - Malignant  SeminomaSeminoma  Non-seminoma (embryonal cell,Non-seminoma (embryonal cell, choriocarcinoma, teratoma, yolk sac)choriocarcinoma, teratoma, yolk sac)  MixedMixed – Non-Germ cell –rare; usually benignNon-Germ cell –rare; usually benign  leydigleydig  sertolisertoli – SecondarySecondary  leukemia, lymphomaleukemia, lymphoma  met (prostate)met (prostate)
  15. 15. Testicular Cancer - GCTTesticular Cancer - GCT  SpreadSpread – LymphaticLymphatic  follows veinsfollows veins  1st echelon nodes1st echelon nodes – retroperitoneal at kidneysretroperitoneal at kidneys  Further tumorFurther tumor – iliac nodesiliac nodes – supraclavicularsupraclavicular  epididymal & skin involvementepididymal & skin involvement lead to inguinal nodeslead to inguinal nodes – hematogeneous and directhematogeneous and direct invasion later (x chorio)invasion later (x chorio)  lung>liver and brainlung>liver and brain
  16. 16. Testicular Cancer - GCTTesticular Cancer - GCT  StagingStaging – TNMTNM – PracticalPractical  low stagelow stage – testis, epi ortestis, epi or cordcord – mild nodesmild nodes  Advanced stageAdvanced stage – skinskin – heavy nodesheavy nodes – hemotogeneoushemotogeneous
  17. 17. Testicular Cancer - GCTTesticular Cancer - GCT  Tumor markersTumor markers  alpha-fetoprotein, human chorionicalpha-fetoprotein, human chorionic gonadotropingonadotropin  well-established role in the diagnosis,well-established role in the diagnosis, staging,staging, prognosis, and follow-up of germ cell tumorsprognosis, and follow-up of germ cell tumors
  18. 18. Testicular Cancer -Testicular Cancer - ImagingImaging  UltrasoundUltrasound  hypoechoic masshypoechoic mass  heterogeneous, echogenic, calcification,heterogeneous, echogenic, calcification, cystic, multiple or completely replace thecystic, multiple or completely replace the testistestis  may show increased vascularitymay show increased vascularity  Small tumors usually hypovascularSmall tumors usually hypovascular  MRIMRI  Isointense on T1W and hypointense on T2WIsointense on T1W and hypointense on T2W
  19. 19. SeminomaSeminoma  Most common GCTMost common GCT  slightly older ageslightly older age – does not occurdoes not occur before pubertybefore puberty  uniform,uniform, hypoechoichypoechoic (hypointense), esp(hypointense), esp when smallwhen small  excellent prognosisexcellent prognosis
  20. 20. SeminomaSeminoma  30 yo with painless30 yo with painless massmass
  21. 21. Large seminomaLarge seminoma
  22. 22. Multifocal SeminomaMultifocal Seminoma
  23. 23. Embryonal carcinomaEmbryonal carcinoma  In 90% of mixedIn 90% of mixed GCT, rarely inGCT, rarely in pure formpure form  MoreMore aggressiveaggressive  Less wellLess well defined and lessdefined and less homogeneoushomogeneous
  24. 24. Yolk Sac TumorYolk Sac Tumor (endodermal sinus(endodermal sinus tumor)tumor)  80% of pediatric80% of pediatric testicular tumorstesticular tumors (Most common in(Most common in children <2yo)children <2yo)  occurs in mixedoccurs in mixed GCT in adultsGCT in adults  Elevated Alpha-Elevated Alpha- fetoproteinfetoprotein
  25. 25. TeratomaTeratoma  #2 tumor in kids#2 tumor in kids  common in mixed GCTcommon in mixed GCT in adultsin adults  tend to be benign in kidstend to be benign in kids more unpredictable inmore unpredictable in adultsadults  complex, cysticcomplex, cystic appearanceappearance  controversial recontroversial re epidermoid cystepidermoid cyst
  26. 26. ChoriocarcinomaChoriocarcinoma  Rare but mostRare but most aggressive GCTaggressive GCT  EarlyEarly hematogeneoushematogeneous mets commonmets common  elevated HcGelevated HcG  Poor prognosisPoor prognosis  HeterogeneousHeterogeneous massmass
  27. 27. Mixed Germ Cell TumorMixed Germ Cell Tumor  More common thanMore common than any other testicularany other testicular tumor excepttumor except seminomaseminoma  Any combination ofAny combination of cell typescell types  variety of cell typesvariety of cell types expressed inexpressed in variablevariable appearanceappearance
  28. 28. ““burned out” Germ Cellburned out” Germ Cell TumorTumor  Phenomenon of patientPhenomenon of patient presents with widespreadpresents with widespread metastatic disease withmetastatic disease with involuted primary tumorinvoluted primary tumor  ?etiology. ?outgrown blood?etiology. ?outgrown blood supplysupply  Primary tumors have a variablePrimary tumors have a variable appearance. Small and can beappearance. Small and can be hypoechoic, hyperechoic, orhypoechoic, hyperechoic, or merelymerelyan area of focalan area of focal calcification.calcification.  Histologic analysis may revealHistologic analysis may reveal minute amounts of residualminute amounts of residual tumor or only dense depositstumor or only dense deposits of collagenof collagen with scatteredwith scattered inflammatory cellsinflammatory cells 22 yo presented with back pain and lower extremity weakness. Initial work-up showed an extradural mass, retroperitoneal adenopathy, and lung metastases. Physical examination of the testes was negative. After biopsy of a cervical node revealed metastatic germ cell tumor, scrotal sonography was performed 22 yo presented with back pain and lower extremity weakness. Initial work-up showed an extradural mass, retroperitoneal adenopathy, and lung metastases. Physical examination of the testes was negative. After biopsy of a cervical node revealed metastatic germ cell tumor, scrotal sonography was performed
  29. 29. CryptorchidismCryptorchidism  6% of full term neonates; 1% at one6% of full term neonates; 1% at one year; 10% bilateralyear; 10% bilateral  Increased risk of:Increased risk of: – Testicular carcinoma (most seminomas)Testicular carcinoma (most seminomas) – InfertilityInfertility  Disordered embryogenesisDisordered embryogenesis  Associated with other GU anomalies:Associated with other GU anomalies: agenesis/ectopy of kidney andagenesis/ectopy of kidney and absence/cyst of SVabsence/cyst of SV  Risk of cancer increased in contra-lateralRisk of cancer increased in contra-lateral testis, even if descendedtestis, even if descended  Risk of cancer not reduced appreciablyRisk of cancer not reduced appreciably with orchiopexywith orchiopexy – Note: single post-pubertal bxNote: single post-pubertal bx recommended to identify intratubularrecommended to identify intratubular germ cell neoplasm (cis) as marked riskgerm cell neoplasm (cis) as marked risk factorfactor
  30. 30. CryptorchidismCryptorchidism  Clinical Problem: nonpalpableClinical Problem: nonpalpable testistestis – DDX: cryptorchidism vs agenesisDDX: cryptorchidism vs agenesis – Important distinctionImportant distinction  Agenesis: no txAgenesis: no tx  Cryptorchidism: orchiopexy atCryptorchidism: orchiopexy at 2yrs; close exam and bx post-2yrs; close exam and bx post- pubescentpubescent – Role of imaging:Role of imaging:  MRI study of choice (US and CTMRI study of choice (US and CT lack specificity)lack specificity) – Laporoscopy: Many feel study ofLaporoscopy: Many feel study of choice (dx and tx)choice (dx and tx)
  31. 31. Retractile TestisRetractile Testis  (Hyper)active cremasteric reflex, prompted(Hyper)active cremasteric reflex, prompted by anxiety, trauma, etc., may pull the testisby anxiety, trauma, etc., may pull the testis out of the scrotum (prescrotal orout of the scrotum (prescrotal or intracanalicular)intracanalicular)  Not uncommon in trauma setting, especiallyNot uncommon in trauma setting, especially in boys (2-3%).in boys (2-3%).  Recommend PE to differentiate retractileRecommend PE to differentiate retractile testis from true cryptorchidismtestis from true cryptorchidism
  32. 32. MicrolithiasisMicrolithiasis  Uncommon (.5%)Uncommon (.5%)  increased associationsincreased associations  cryptorchidism,cryptorchidism, infertility, Klinefelterinfertility, Klinefelter syndrome, Downsyndrome, Down syndrome, alveolarsyndrome, alveolar microlithiasis, and,microlithiasis, and, mostmost important,important, testiculartesticular carcinomacarcinoma  Calculi withinCalculi within Seminiferous tubulesSeminiferous tubules
  33. 33. MicrolithiasisMicrolithiasis  US diagnosisUS diagnosis  5 or more5 or more calcificationcalcification  may be bl andmay be bl and diffuse or focaldiffuse or focal  Risk or coexistentRisk or coexistent or subsequentor subsequent carcinomacarcinoma controversialcontroversial  as is need andas is need and duration of us followduration of us follow upup
  34. 34. Non-Germ cell tumorsNon-Germ cell tumors  5% of testicular cancer5% of testicular cancer  higher in pedshigher in peds  Sertoli (sex cord) and LeydigSertoli (sex cord) and Leydig (interstitial) cell(interstitial) cell  Also other rare cell linesAlso other rare cell lines  90% benign90% benign  Indistinguishable from GCTIndistinguishable from GCT  Calcifying Sertoli Cell TumorCalcifying Sertoli Cell Tumor  pediatric age grouppediatric age group  multiple calcified massesmultiple calcified masses  PJ and Carney syndromePJ and Carney syndrome
  35. 35. LymphomaLymphoma  5% of testicular tumor5% of testicular tumor  #1 in over 50 y/o#1 in over 50 y/o  only 1% of lymphomaonly 1% of lymphoma patientspatients  May beMay be  only site of diseaseonly site of disease  along with other diseasealong with other disease  site of recurrencesite of recurrence  AppearanceAppearance  Indistinguishable fromIndistinguishable from GCTGCT  Multiple, bl hypoechoicMultiple, bl hypoechoic nodulesnodules
  36. 36. Leukemia and MetsLeukemia and Mets  Common site of recurrenceCommon site of recurrence  primary disease uncommon hereprimary disease uncommon here  Appearance variableAppearance variable  uni or bluni or bl  focal or diffusefocal or diffuse  hypo or hyperechoichypo or hyperechoic  Solid organ metsSolid organ mets  rare; usually disease widespreadrare; usually disease widespread  prostate and lungprostate and lung
  37. 37. Tumor-like lesionsTumor-like lesions  ““intratesticular mass is cancer untilintratesticular mass is cancer until proven otherwise”proven otherwise”  Traditional teaching: 95% malignantTraditional teaching: 95% malignant  BUT, more benign lesions being identifiedBUT, more benign lesions being identified  Not all testicular lesions are tumorsNot all testicular lesions are tumors  As many as 30% of orchiectomies for testicular lesionsAs many as 30% of orchiectomies for testicular lesions end up being benignend up being benign ((Haas GP, Shumaker BP, Cerny JC. The high incidence ofHaas GP, Shumaker BP, Cerny JC. The high incidence of benign testicular tumors. J Urolbenign testicular tumors. J Urol 19861986;136:1219 -1220);136:1219 -1220)  recognition of these entities may prevent needlessrecognition of these entities may prevent needless orchiectomyorchiectomy  Still, rather needless orchiectomy thanStill, rather needless orchiectomy than missed cancer. Thus will havemissed cancer. Thus will have orchiectomy for benign disease.orchiectomy for benign disease.
  38. 38. Tumor-like lesionsTumor-like lesions  DDX:DDX:  orchitisorchitis  Hematoma/contusionHematoma/contusion  infarctinfarct  cyst (see next)cyst (see next) – mimics teratomamimics teratoma  adrenal restsadrenal rests – 2% of adults have2% of adults have – Enlarged in CAH orEnlarged in CAH or rarely Cushingsrarely Cushings – BL hypo massesBL hypo masses  sarcoidosissarcoidosis  sperm extractionsperm extraction
  39. 39. Sperm Extraction*Sperm Extraction*  Sperm extraction forSperm extraction for infertility are becominginfertility are becoming more commonmore common  In a % (varies from20-In a % (varies from20- 80%) Focal testicular80%) Focal testicular lesions can resultlesions can result  ?hematoma, infarct?hematoma, infarct  FindingsFindings  anterior andanterior and subcapsularsubcapsular  hypoechoichypoechoic  hyperechoic, calcifichyperechoic, calcific  History may allow closeHistory may allow close F/UF/U *S Strauss, AJR 2001 176: 113
  40. 40. Intra-testicular CystsIntra-testicular Cysts  OverviewOverview  Tunica Albuginea cystsTunica Albuginea cysts  Simple cystSimple cyst  Cystic transformation of the rete testesCystic transformation of the rete testes  epidermoidepidermoid  intratesticular spermatoceleintratesticular spermatocele  Intratesticular varicoceleIntratesticular varicocele  AbscessAbscess  InfarctInfarct
  41. 41. Tunica Albuginea CystTunica Albuginea Cyst  ?etiology?etiology  Middle ageMiddle age  Key to diagnosisKey to diagnosis  peripheral locationperipheral location  simple cystsimple cyst  usually 2-5 mmusually 2-5 mm
  42. 42. Simple CystSimple Cyst  Usually >40 yoUsually >40 yo  2mm to 2cm2mm to 2cm  single or multiplesingle or multiple  Usually nearUsually near mediastinummediastinum
  43. 43. EpidermoidEpidermoid  Keratonizing squamousKeratonizing squamous epithelium filled withepithelium filled with cheesy laminated stuffcheesy laminated stuff  appearanceappearance  echogenic rimechogenic rim  ““onion skinned” due toonion skinned” due to layerslayers  ““solid” appearingsolid” appearing  avascularavascular
  44. 44. EpidermoidEpidermoid  Unable to totallyUnable to totally exclude solid lesionexclude solid lesion usually andusually and orchiectomy oftenorchiectomy often neededneeded  MRIMRI  high signal on T1high signal on T1 and T2and T2
  45. 45. Cystic Transformation ofCystic Transformation of the Rete Testisthe Rete Testis  Due to obstruction of efferentDue to obstruction of efferent ductules with resultant ectasiaductules with resultant ectasia  older menolder men  FindingsFindings  uni or bluni or bl  tubular cystic areastubular cystic areas  in/near mediastinumin/near mediastinum  epididymal cystsepididymal cysts  DDX: cystic GCT (esp teratoma)DDX: cystic GCT (esp teratoma)  usually has soft tissueusually has soft tissue  not tubularnot tubular  MRI can may be helpfulMRI can may be helpful
  46. 46. Intra-testicularIntra-testicular SpermatoceleSpermatocele  Near mediastinumNear mediastinum  cystic, can becystic, can be septatedseptated  containscontains spermatozoaspermatozoa
  47. 47. Intras-testicularIntras-testicular VaricoceleVaricocele  ?etiology. ??etiology. ? significancesignificance  May cause painMay cause pain  (+-)extratesticular(+-)extratesticular varicocelesvaricoceles  FindingsFindings  tubular, serpigineoustubular, serpigineous structures withstructures with venous doppler/colorvenous doppler/color flow which increasesflow which increases with valsalvawith valsalva
  48. 48. Testicular TorsionTesticular Torsion  Most common in adolescentsMost common in adolescents  Acute scrotumAcute scrotum  DDXDDX – torsiontorsion – orchitisorchitis – traumatrauma – tumortumor  Due to “bell and clapper”Due to “bell and clapper” deformitydeformity  lackof normal fixation in thelackof normal fixation in the scrotumscrotum  Urologic EmergencyUrologic Emergency  salvage rate related to timesalvage rate related to time – 90%-100% detorsion within 690%-100% detorsion within 6 hours of painhours of pain – 20%-50% after 12 hours20%-50% after 12 hours – 0%-10% if detorsion greater0%-10% if detorsion greater than 24 hoursthan 24 hours  consider doing own USconsider doing own US
  49. 49. Testicular TorsionTesticular Torsion  FindingsFindings  Early, testis is normal; laterEarly, testis is normal; later becomes enlarged andbecomes enlarged and hypoechoichypoechoic  Lack ofLack of SignificantSignificant detectable flowdetectable flow  reactive hydrocelereactive hydrocele
  50. 50. Torsion of AppendigesTorsion of Appendiges Torsed appendix testis
  51. 51. Scrotal TraumaScrotal Trauma  2 Categories2 Categories  penetrating (surgery)penetrating (surgery)  blunt (imaging)blunt (imaging)  TesticularTesticular Fracture/ruptureFracture/rupture  disruption of t. albugineadisruption of t. albuginea with bleeding andwith bleeding and extrusion of S.T.extrusion of S.T.  surgical emergencysurgical emergency  Trauma inducedTrauma induced torsion/Infarct a knowtorsion/Infarct a know complicationcomplication Types of injury: Contusion Hematoma Fracture/rupture hematocele Types of injury: Contusion Hematoma Fracture/rupture hematocele
  52. 52. Scrotal TraumaScrotal Trauma  UltrasoundUltrasound  Normal - excludes seriousNormal - excludes serious injuryinjury  hematoma - echogenic orhematoma - echogenic or hypoechoic; roundedhypoechoic; rounded  Hematocele - extratesticularHematocele - extratesticular fluid; echoes or echogenicfluid; echoes or echogenic  Infarct - absent flowInfarct - absent flow  FractureFracture – Heterogeneous testicle;Heterogeneous testicle; diffuse or focaldiffuse or focal – irregular or ill-defined contourirregular or ill-defined contour or bulgeor bulge – often just a “often just a “messmess””
  53. 53. Scrotal TraumaScrotal Trauma  MRIMRI – May play future roleMay play future role in detection ofin detection of disruption of thedisruption of the tunica albuginea (ietunica albuginea (ie rupture)rupture)
  54. 54. Scrotal Trauma:Scrotal Trauma: extremeextreme mountain bikersmountain bikers.. Krauscher F Radiology 2001May;219(2):427-31USKrauscher F Radiology 2001May;219(2):427-31US
  55. 55. Inflammatory DiseaseInflammatory Disease  Epididymitis/orchitisEpididymitis/orchitis  usually retrotrade infection from bladder and prostateusually retrotrade infection from bladder and prostate  rarely traumatic, surgical, etcrarely traumatic, surgical, etc  orchitis from epididymitis (except mumps)orchitis from epididymitis (except mumps)  ““acute scrotum” in adolescents (kids,acute scrotum” in adolescents (kids, elderly)elderly)  testicular torsiontesticular torsion  traumatrauma  infectioninfection  torsion of epididymal or testicular appendagestorsion of epididymal or testicular appendages  Imaging is to confirm diagnosis andImaging is to confirm diagnosis and excluded complication (surgery)excluded complication (surgery)  abscessabscess  infarctioninfarction
  56. 56. Inflammatory DiseaseInflammatory Disease  Ultrasound FindingsUltrasound Findings – involves epididymisinvolves epididymis plus/minus testisplus/minus testis  focal or diffusefocal or diffuse enlargementenlargement  hypoechogenicityhypoechogenicity  INCREASED FLOWINCREASED FLOW  reactive hydrocelereactive hydrocele  Nuclear medicineNuclear medicine  increased flow andincreased flow and activityactivity
  57. 57. Inflammatory DiseaseInflammatory Disease  MRIMRI  edema andedema and inflammation oninflammation on T2WT2W  increasedincreased enhancementenhancement
  58. 58. Orchitis with InfarctionOrchitis with Infarction  58 yo with scrotal58 yo with scrotal pain and swellingpain and swelling for 4 daysfor 4 days
  59. 59. ExtratesticularExtratesticular PathologyPathology  Normal Extratesticular VariantsNormal Extratesticular Variants  Spermatocele and epididymal cystSpermatocele and epididymal cyst  Sperm granulomaSperm granuloma  VaricoceleVaricocele  HydroceleHydrocele  HerniaHernia  Extratesticular TumorExtratesticular Tumor
  60. 60. Extratesticular VariantsExtratesticular Variants  Appendix of theAppendix of the epididymisepididymis  Isoechoic to epididymisIsoechoic to epididymis  May calcifyMay calcify  Appendix of the testesAppendix of the testes  Isoechoic to testesIsoechoic to testes  Cyst of MorgagniCyst of Morgagni  Dilation of theDilation of the paradidymisparadidymis  Cystic; can appearCystic; can appear solidsolid
  61. 61. Spermatocele andSpermatocele and epididymal cystepididymal cyst  very commonvery common  usually within/near head ofusually within/near head of epididymisepididymis  usually asymptomatic andusually asymptomatic and present incidently or aspresent incidently or as palpable masspalpable mass  Epididymal CystEpididymal Cyst  Cystic on USCystic on US  SpermatoceleSpermatocele  UltrasoundUltrasound – Cystic (may not be ableCystic (may not be able to differentiate fromto differentiate from epididymal cyst)epididymal cyst) – Low level echoesLow level echoes – Rarely hyperechoicRarely hyperechoic
  62. 62. Sperm GranulomaSperm Granuloma  Sperm extravasationSperm extravasation can result in granulomacan result in granuloma formationformation  Often occurs afterOften occurs after vasectomyvasectomy  Painful (unlike tumor)Painful (unlike tumor)  UltrasoundUltrasound  Isoechoic toIsoechoic to hyperechoic mass inhyperechoic mass in the epididymisthe epididymis  Rarely may calcifyRarely may calcify
  63. 63. VaricoceleVaricocele  Dilated intrascrotal veinsDilated intrascrotal veins  incompetent valvesincompetent valves in testicular veinsin testicular veins  rarely due to mass,rarely due to mass, etcetc  Worry about unilateralWorry about unilateral right sided varicoceleright sided varicocele  Infertility, heavinessInfertility, heaviness  Common (15-20%)Common (15-20%)  FindingsFindings  L>R, bl commonL>R, bl common  veins > 2-3mmveins > 2-3mm  dilation excacerbateddilation excacerbated by valsalva andby valsalva and standingstanding
  64. 64. Hydrocele (hematoceleHydrocele (hematocele & pyocele& pyocele  Fluid w/I tunica vaginalisFluid w/I tunica vaginalis  HydroceleHydrocele – Small amount of fluid normalSmall amount of fluid normal – EtiologiesEtiologies  congenital - persistent peritonealcongenital - persistent peritoneal communicationcommunication  AcquiredAcquired – Reactive(trauma, infection, torsion)Reactive(trauma, infection, torsion) – In adults, not uncommon withIn adults, not uncommon with unknown etiology (diminishedunknown etiology (diminished reabsorbtion)reabsorbtion)  HematoceleHematocele – Echogenic fluid; trauma, tumor orEchogenic fluid; trauma, tumor or surgerysurgery  PyocelePyocele – Echogenic collection; septations andEchogenic collection; septations and debrisdebris
  65. 65. HerniaHernia  Via patentVia patent processus vaginalisprocessus vaginalis  complex masscomplex mass  look for peristalsislook for peristalsis
  66. 66. Extratesticular tumorExtratesticular tumor  Rare, mostly benignRare, mostly benign  Adenomatoid tumorAdenomatoid tumor  Only tumor with anyOnly tumor with any frequencyfrequency  HamartomatousHamartomatous lesionlesion  Adolescents andAdolescents and young adultsyoung adults  Tail of epididymisTail of epididymis most common sitemost common site  Isoechoic toIsoechoic to hyperechoichyperechoic
  67. 67. ReviewReview  Solid massSolid mass – GCTGCT  SeminomaSeminoma  Non-seminomaNon-seminoma – Embryonal, yolk sac, teratoma, choriocarcinoma, mixedEmbryonal, yolk sac, teratoma, choriocarcinoma, mixed – Sertoli; LeydigSertoli; Leydig – Secondary (Lymphoma, mets)Secondary (Lymphoma, mets) – MimicsMimics  Orchitis, trauma, infarct, adrenal, sarcoid, sperm extractionOrchitis, trauma, infarct, adrenal, sarcoid, sperm extraction – Cystic lesionsCystic lesions  EpidermoidEpidermoid  Cystic lesionsCystic lesions  Tunica Albuginea cystsTunica Albuginea cysts  Simple cystSimple cyst  Cystic transformation of the rete testesCystic transformation of the rete testes  epidermoidepidermoid  intratesticular spermatoceleintratesticular spermatocele  Intratesticular varicoceleIntratesticular varicocele  AbscessAbscess  InfarctInfarct  TorsionTorsion  TraumaTrauma  EpidimoorchitisEpidimoorchitis  Extratesticular DiseaseExtratesticular Disease – Normal Extratesticular VariantsNormal Extratesticular Variants – Spermatocele and epididymal cystSpermatocele and epididymal cyst – Sperm granulomaSperm granuloma – VaricoceleVaricocele – HydroceleHydrocele – HerniaHernia – Extratesticular TumorExtratesticular Tumor  Adenomatoid tumorAdenomatoid tumor

×