Testis carcinoma- imaging

IMAGING INTESTICULAR
CANCER
DEPT OF UROLOGY
GOVT ROYAPETTAH HOSPITAL AND KILPAUK MEDICAL COLLEGE
CHENNAI
1

MODERATORS:
Professors:
• Prof. Dr. G. Sivasankar,M.S., M.Ch.,
• Prof. Dr.A. Senthilvel,M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan,M.S., M.Ch.,
• Dr. R. Bhargavi,M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam,M.S., M.Ch.,
• Dr. D.Tamilselvan,M.S., M.Ch.,
• Dr. K. Senthilkumar,M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai.
2

WHYWE NEED IMAGING ????
• Diagnosis
• Staging
• Surveillance & Follow up
3

IMAGING MODALITIES
• ULTRASONOGRAPHY SCROTUM
• CECTABDOMEN &PELVIS
• CT CHEST
• MRI ABDOMEN/LNP MRI
• CT/MRI BRAIN
• 18 F-FDG PET/CT
4

DIAGNOSIS
5

ULTRASONOGRAPHY
• USG Scrotum
Color Doppler
Contrast enhanced Usg
Sonoelastography
USGAbdomen and pelvis
6

ULTRASONOGRAPHY SCROTUM
High-frequency USG(7-18 MHz) with a linear-array
transducer with color doppler mode is the initial imaging
modality used in evaluation of a suspected testicular mass .
Accurate in localizing
lesions as intratesticular
or extratesticular,an
important distinction
since most intratesticular
masses are malignant .
Excellent in
differentiating benign
cysts from solid or
complex testicular
masses.
7

TECHNIQUE
• The examination should be carried out in a quiet room that is adequately
warm for patient comfort.
• The patient should be supine with the scrotum supported on a towel or on
the anterior thighs.
1. The patient should be draped in such a way as to hold the penis out of
the way and to ensure patient privacy.
2. Copious amounts of conducting gel should be used to provide a good
interface between the transducer and the scrotal skin.
3. Air trapping by scrotal hair results in unwanted artifacts..
8

• Excessive pressure results in
movement of testis or compression
of the testis.
• Change echogenicity and obscure
fine anatomic detail
• Alter volume measurements
Complete gentle
contact between skin
and transducer is
essential .
9

NORMAL USG SCROTUM
• Imaging :
Sagittal view
Transverse view
• The sagittal view should proceed from the midline medially
and then laterally and from the midtransverse section of the
testis to the upper pole and the lower pole of the testis.
• The epididymis and entire scrotal contents should be imaged.
10

TESTIS :OVOID AND
HOMOGENOUS IN
ECHOGENICITY.
Testicular parernchyma:
Medium to low echogenicity
,finely granular appearance
which is slightly hypoechoic
/equal to when compared with
epididymal head.
11

MEDIASTINUMTESTIS :
Invagination of tunica
albuginea into body of the
testis.
Bright echogenic line within
testicular parenchyma
12

• Epididymis : Slightly sonoluscent located posterolateral to
testis.
• Rete testis : Network of tubules that carry sperm from
testis to epididymis.
• Normally not seen, when dilated appears as a focus of
anechoic tubular structures without a solid componemt
following the course of mediastinum.
13

14

DOPPLER ULTRASONOGRAPHY
Doppler ultrasonography depends on the physical principle of
frequency shift when sound waves strike a moving object.
Sound waves of a certain frequency
are shifted or changed on the basis
of
1. the direction and velocity of
the moving object
2. the angle of insonation.
This phenomenon
allows for the
characterization of
motion,most
commonly the
motion of blood
through vessels.
15

COLOR DOPPLER
ULTRASONOGRAPHY
Allows for evaluation of the velocity and direction of motion.
The velocity of motion is designated by the intensity of the color.
The brighter the color,the greater the velocity.
A color map:
Blue to the motion away from the
transducer
Red to motion toward the transducer.
16

COLOR FLOW WITH SPECTRAL DISPLAY
Evaluate the pattern and velocity of blood flow
Displays the flow as a continuous waveform
The waveform provides information about
peripheral vascular resistance in the tissues.
The most commonly used index of these velocities
is the RESISTIVE INDEX.
RI=PSV-EDV /PSV
17

18

POWER DOPPLER ULTRASONOGRAPHY
Assigns the amplitude of frequency change to a color map.
More sensitive mode
for detecting blood
flow.
Less affected by
backscatter waves
This mode does not permit evaluation of velocity
or direction of flow .
Power
Doppler is
less angle
dependent
than color
Doppler.
19

20

PULSED DOPPLER ULTRASOUND
Combines the velocity detection of continuous wave Doppler
with the range discrimination of a pulse echo system.
Short bursts of ultrasound are transmitted at regular intervals
The echoes are demodulated as they return
Pulses are received in sufficiently rapid succession
The output of the demodulator
Sequence of samples from which Doppler signal can be
synthesized.
21

COLOR FLOW & PULSED DOPPLER
OF TESTIS(NORMAL VALUES)
Low impdedance flow within parenchyma
Mean PSV (Peak systolic velocity) : 9.7-11 cm/sec
Mean EDV (End diastolic velocity) : 3.6-5 cm/sec
Normal value of RI :0.55-0.62
Measure of distal impedance
22

USG ABDOMEN &PELVIS
• If the testis is located within the pelvis /inguinal canal ,it
can be identified with confidence .
• Usually undescended testis smaller ,ovoid ,and slightly less
echognic than normally descended testis.
23

SEMINOMATESTIS
Well circumscribed hypoechoic mass
with marked internal vascularity
24

NSGCT
Heteroechoic appearance
with cystic spaces and
calcification
ILL defined margin
25

LYMPHOMA
Hypoechoic and hypervascular
B/L
26

LEYDIG CELLTUMOR
Well circumscribed hypoechoic mass
with internal vascularity
27

MIMICS OFTESTICULAR
SEMINOMA
BENIGN
• Segmental infarction
• Testicular hematoma
• Orchitis
• Epidermoid cyst
• Adrenal rest
• Sarcoidosis
• Sex cord stromal tumors
• Splenogonadal fusion
MALIGNANT
• NSGCT
• Lymphoma
• Metastases
28

29

SONOELASTOGRAPHY
The ability to evaluate the elasticity (compressibility and
displacement) of biologic tissues.
Essentially,it gives a representation,using color,
of the softness or hardness of the tissue of
interest.
Real-time elastography (RTE)
Shear wave elastography (SWE).
30

Young’s modulus or elasticity (E):
E=S/ e
E=Elasticity
S=Stress
e=Strain
E is larger in hard tissues
Lower in soft tissues.
Visually,the elasticity of a tissue is
represented by color spectrum.
The color given to hard lesions is determined by the
manufacturer of the equipment and can be set by the user
31

RTE
Deformation is induced by manually pressing on
the anatomy with the transducer and is measured
using ultrasonography.
32

Benefits
High spatial
resolution
It is a real-time
measurement
Demerits:
Qualitative
technique and
highly user
dependent.
Unable to
measure absolute
tissue stiffness .
33

SWE
Low-frequency (approximately 100 hz) pulses are rapidly transmitted
into the tissue
Induce a vibration in the tissue( in a single area or in a vertical plane
by rapidly altering focal depth)
The propagation velocity of the resultant transient shear waves
The viscoelastic properties of the tissues
34

LIMITATIONS OF SWE
Only a few millimeters of
propagation
Detection of shear wave propagation requires
very rapid acquisition speeds (pulse repetition
frequency is >5000 Hz),which may limit the
area of detection.
35

SONOELASTOGRAPHY (RTE)
36

SONOELASTOGRAPHY (SWE)
37

CONTRAST ENHANCED
ULTRASONOGRAPHY
Microbubbles used for enhancing the echogenicity of blood and tissue.
Microbubbles are distributed in the vascular system , create strong
echoes with harmonics when struck by sound waves.
The bubbles themselves are rapidly degraded by their interaction with
the sound waves.
Useful by enhancing the ability to recognize
areas of increased vasculature.
Rapid wash in & rapid wash out in case of
malignant lesions of testis.
38

SEMINOMA
39

LEYDIG CELLTUMOR
40

MAGNETIC RESONANCE IMAGING
SCROTUM
• TECHNIQUE:
1.5-T magnet is used for imaging the scrotum.
The patient is placed supine on the table feet first.
A folded towel is placed between the patient’s thighs to elevate the
scrotum to a horizontal plane.
The penis is taped to the abdominal wall out of the area of interest
A 12.5-cm circular multipurpose surface coil is centered over the
scrotum,with the bottom of the coil over the caudal tip of the scrotum.
Axial and coronalT1 andT2 weighted images are acquired
41

MRI SCROTUM
The normal testis is a
sharply demarcated
homogeneous oval structure
Low to intermediate signal
intensity onT1-weighted
images
High signal intensity onT2-
weighted images
42

THETESTIS IS
SURROUNDED BY
THETUNICA
ALBUGINEA,WHICH
HAS LOWT1 ANDT2
SIGNAL INTENSITY
Mediastinum testis has
signal intensity similar to
that of the testis on T1-
weighted images .
Lower in signal intensity
than the testis on T2-
weighted image.
43

• The epididymis is slightly heterogeneous and isointense to the
testis onT1-weighted images.
• The epididymis is more clearly differentiated from the testis on
T2-weighted images because it has lower signal intensity than
the adjacent testis.
• Contrast material–enhanced images demonstrate
homogeneous enhancement of the testis and hyperintensity of
the epididymis relative to the testis.
• The scrotal wall is typically hypointense onT1- andT2-
weighted images
44

• Diffusion-weighted imaging is useful for detection of malignant
neoplasms.
• Is largely dependent on the extent of tissue cellularity, densely packed
neoplastic cells, and enlargement of nuclei, all of which are associated
with restricted diffusion owing to the reduced mobility of water
molecules.
• The mean ADC values for normal testicular parenchyma are in the
range of 1.08–1.31 10-3 mm2/sec, depending on patient age.
• Lower in malignant lesions than in benign lesions or normal tissue
45

SEMINOMA
TESTIS
Relatively homogeneous in
signal intensity.
Usually hypointense to normal
testis onT2-weighted images.
Fibrovascular septa may be
detected as bandlike areas of
low signal intensity onT1- and
T2-weighted images that
enhance to a greater degree
than the tumor.
46

NSGCT
Nonseminomatous germ cell
tumors have heterogeneous
signal intensity .
Characteristics and
enhancement indicative of
necrosis and hemorrhage.
47

LEYDIG CELLTUMOR
Isointense onT1-weighted images.
Hypointense onT2-weighted images
compared with the normal testis,
with marked homogeneous
enhancement.
Capsular high signal intensity onT2-
weighted images.
May have a high-signal-intensity
central scar onT2-weighted images.
48

SERTOLI CELLTUMOR
Multiple nodules with
homogeneous intermediate
signal intensity onT1-
weighted images
High signal intensity onT2-
weighted images with rim
enhancement
49

LYMPHOMA
Low signal intensity onT1- andT2-
weighted images, with low-level
enhancement (less than the
normal testis).
Infiltrative pattern is common.
The diagnosis of lymphoma should
be considered if there is
involvement of both the testis and
the epididymis.
50

STAGING
51

IMAGING MODALITIES
• CECTABDOMEN & PELVIS
• CT CHEST
• BRAIN CT/MRI(Symptomatic patient ,High B-HCG values)
• BONE SCAN (Symptomatic patient)
52

CECT ABDOMENAND PELVIS
CT with IV and oral contrast
administration is the reference standard
for evaluation of retroperitoneal
lymphadenopathy and the abdominal
viscera.
Staging of retroperitoneal disease
depends on nodal size.
Sensitivity :70-80%
53

MALIGNANT LYMPH NODESARE
IDENTIFIED BASED ON SIZE
CRITERIA,WITH MALIGNANT
NODES USUALLY CONSIDERED
TO BE 10 MM OR GREATER IN
DIAMETER.
54

MRI ABDOMEN
High dose of radiation
during CT Abdomen
Relatively young age of
testicular cancer
patients
MRI as a potential
modality for
retroperitoneal lymph
node evaluation
55

MRI ABDOMEN
CECT ABDOMEN/USG
Inconclusive
Allergy to contrast media
containing iodine
MRI IS AN OPTIONAL IMAGING
CURRENTLY NO USE IN STAGING OF CATESTIS
56

57

LYMPHOTROPHIC NANOPARTICLE
ENHANCED MRI
Superparamagnetic iron
oxide nanoparticles
Small enough to pass
freely from the venous
system into the
medullary sinuses of
lymph nodes where
they are phagocytosed
by macrophages of the
reticuloendothelial
system.
58

1. 24–36 hours after contrast administration because of the
specific bioavailability properties of the nanoparticles.
2. Individual nodes are typically compared with each other in
separate scans before and after contrast
Benign lymph nodes have normally functioning
macrophages that avidly take up these particles.
Macrophages in lymph nodes infiltrated with tumor
have dysfunctional phagocytosis.
59

The disparity in nanoparticle take-up
results in differential enhancement of
benign and malignant lymph nodes
on MRI
60

61

CHEST IMAGING
Testicular cancer has propensity to spread to the mediastinal lymph
nodes after reaching the retroperitoneum.
1. Plays an important role in
initial staging .
2. CT chest is the most
sensitive evaluation.
1. Recommended in all
patients of testicular
cancer.
2. Upto 10% of patients
can present with
small subpeural nodes
not visible on chest
X- ray .
62

63

BRAIN IMAGING( CT/MRI BRAIN)
1. Neurologically symptomatic patient
2. Extensive pulmonary disease
3. High suspicion for brain metastases
4. Choriocarcinoma in orchidectomy specimen & persistently
elevated Beta HCG
64

PET/CT IMAGING
18 F-FDG PET/CT :
Not presently included in the initial staging of testicular malignancy due
to lack of evidence .
Recommended in follow
up of patients with
seminoma ( >8 wks post
last cycle of
chemotherapy) residual
retroperitoneal disease .
Not
recommended in
restaging of
patients with
NSGCT after
chemotherapy.
65

PET/CT IMAGING
66

SURVEILLANCE & FOLLOW UP
STAGE I
SEMINOMA
Y 1 Y 2-3 Y 4-5
ON SURVEILLANCE CECT ABD/PELVIS
3,6,12 MONTHLY
EVERY 12 MONTH AT 60 MONTHS
ADJUVANT CT/RT CECT
ABDOMEN/PELVIS
ANNUALLY AT 60 MONTHS
67

68

69

70

71

EAU GUIDELINES
TEST RECOMMENDATION STRENGTH
RATING
Testis ultrasound
(bilateral)
All patients Strong
Abdominopelvic
computed
tomography (CT)
All patients Strong
Chest CT All patients Strong
72

EAU GUIDELINES
TEST RECOMMENDATION STRENGTH
RATING
Bone scan/MRI In case of symptoms Strong
BRAIN CT/MRI In case of symptoms and patients
with metastatic disease with
multiple lung metastases/high Beta
HCG values
Strong
73

THANK YOU
74

Testis carcinoma- imaging

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