William
G. Horstman,
Testicular with Color
MD
G. Leland
MD
Melson,
#{149}
Tumors: Doppler
William
D. Middleton,
#{149}
MD
Gerald
L. Andriole,
#{149}
MD
Findings US’
A study of 28 patients with surgically proved testicular tumors was performed to determine the appearance at color Doppler ultrasound (US) scanning. There was a general correlation of tumor size and vascularity. Twenty
of 21 (95%)
tumors
larger
than 1.6 cm were hypervascular. Six of seven (86%) tumors smaller than 1.6 cm were hypovascular. One small, 1.1-cm-diameter seminoma was hypervascular, and one 2.8-cm-diameter seminoma was hypovascular. The histologic findings of the tumor did not correlate with the vascularity of the lesion as seen at color Doppler US. Resistive indexes ranged from .476 to 1.0 (mean, 0.70). Peak systolic velocities ranged from 8.4 cm/sec to 64.9 cm/sec (mean, 9.8 cm/sec). Venous flow was detected in eight himors. The gray-scale findings, as well as history and physical examination findings, correctly suggested a neoplasm in all cases. The findings at color Doppler US were prospectively interpreted as indicative of neoplasm in 27 cases and as indicative of inflammation in one case. The authors conclude that color Doppler US scanning has only a limited role in the evaluation of testicular tumors. Index
terms:
neoplasms, trasound Radiology
Scrotum, US, 847.12984 #{149} Testis, 847.32 #{149} Testis, US, 847.12984 #{149} UI(US), Doppler studies, 847.12984 1992;
185:733-737
1.
2.
Figures
1, 2. (1) Transverse view of the testis of patient I demonstrates a hypoechoic, hypovascular, 4 x 5-mm seminoma (straight arrow). Normal centripedal arteries (curved arrow) and recurrent rami (arrowhead) are seen coursing through the testis. (2) Longitudinal view of the testis of patient 6 shows a hypovascular 1.4 x 1.0-cm Leydig cell tumor (T).
H
gray-scale (US) has
IGH-RESOLUTION
sonography
long
evaluate
ultrabeen
the standard of reference for the imaging evaluation of testicular masses. The appearance of neoplasms at US has
been
well
described
lar scintigraphy, phy,
and
(1,2).
computed
magnetic
The study
tomogra-
tients,
imaging
offer little additional information in imaging scrotal masses except in unusual situations. Color Doppler US is a relatively new modality in scrotal imaging
that
can
readily
display
nor-
mal testicular vascular anatomy (3). Many recent articles have shown the usefulness of color Doppler US in evaluation of acute scrotal disorders,
From the Mallinckrodt Institute of Radiology (W.G.H., G.L.M., W.D.M.) and the Department of Urologic Surgery (G.L.A.), Washington University
of Medicine, 510 S Kingshighway Blvd, St Louis, MO 631 10. Received May 12, 1992; revision requested June 26; revision received July 2; accepted July 6. Address reprint requests to G.L.M. RSNA, 1992
,.
School
in detail.
Since
performed in most pected tumors, the lesions
raphers. spectively surgically
must
be
US
patients
findings understood
scanning
with
proved
testicular
is
sus-
in these by sonog-
We prospectively and evaluated 28 patients
Doppler
METHODS
consisted
17-68
years
of 28 pa-
(mean,
36 years),
who were examined between March 1988 and March 1992. The presenting symptom was
a palpable
tients small
mass
the tumors lesions were
in 22 cases.
In six pa-
were nonpalpable: incidental findings
Two in
patients tal pain
being evaluated for chronic seroor infertility; three were metastatic
disease
(subsequently,
a small
in all patients.
any
patients
this tive
time US.
with were
Standard
verse
testicular
phased
preopera-
gray-scale
images
in trans-
testis
QAD-1 Issaquah,
were
unit
color performed
(Quantum
Wash).
ob-
7.5-MHz
All examinawith
Twenty-two
were
by using
transducers.
performed
aminations
planes
if
during
without
linear were
tumors
treated
in each
supine.
to
We do not know
testicular
and longitudinal
tamed tions
retrowith
tumors
AND
group
aged
formed
(4-8). To our knowledge, the appearance of testicular tumors at color Doppier US has not been previously deseribed
at color
tumor was visualized at US); and one was in a patient with acute scrotal pain. Grayscale US and color Doppler US were per-
especially in differentiating inflammatory conditions from testicular torsion
I
findings
MATERIALS
Testicu-
resonance
the
US.
the
patients
Doppler on
US exa model
Medical
Systems,
Six examinations
were
733
Doppler
Color
US Results
in 25 Patients
with Testicular
Tumors Peak Systolic
Patient
No.
Tumor Size (cm)
Age (y)
Patient
1 2
0.4 x 0.5 1.0 x 1.0
39 25
1.1 1.1 1.2 1.4 1.6 1.7
x x x x x x
0.85 1.0 1.3 1.0 1.6 1.5
cell tumor, embryonal
28 28 31 32 30 25
Seininoma
Seminoma
Leydig cell Teratoma Mixed germ cell tumor, inoma, embryonal
1.8 x 1.8 2.2 x 2.3 2.5 x 2.0
36 39 23
12 13 14 15 16 17
2.5 x 2.5
63
2.6 x 2.4 2.8 x 2.5
33
2.8 x 2.8 3.0 x 2.0 3.0 x2.4
32 35 21
18 19
3.0 x 2.5 3.2 x 3.0
34 26
Mixed
20
3.2 x 3.0
17
Mixed
NA
ND
NA
NA
ND
Hypervascular Hypovascular Hypovascular Hypovascular Hypovascular
.476 NA NA NA NA
Hypervascular
.563
10.7 NA NA NA NA 14.2 18.3 NA 19.8 33.2 30.0 NA NA NA
No ND ND ND ND Yes
sem-
Seminoma
embryonal,
germ cell
yolk teratoma tumor, sam-
Mixed
68
inoma, embryonal MIxed germ cell tumor, bryonal, yolk sac
emsem-
ND
Hypervascular
1.0
20.3
Yes
.912
47.2
No
Hypervascular
NA
NA
ND
Hypervascular
.588 NA
18.2 NA
No ND
Hypervascular
.512 .517
25.4 17.6
No
.531
19.2
Yes
.874 .696 NA
64.9 24.7 NA
Yes
testis
25
Leukemic
26
Entire
Seminoma
Entire
testis testis
42
27
63
Lymphoma
Hypervascular Hypervascular
28
Entire
testis
32
Seminoma
Hypervascular
color were
noise. Pulsed prospectively
Doppler studied
in
some cases to differentiate arterial from venous flow and to characterize arterial
flow. Resistive
indexes
were
prospectively
and retrospectively calculated whenever an arterial waveform was obtained. The resistive indexes of the seminomas and nonseminomatous germ cell tumors were
compared
by means
rank-sum
test.
Each US examination
#{149} Radiology
Doppler
infiltration
and no venous
performed
in the uninvolved
testis,
Hypervascular
portion
flow detected,
of the ipsilateral
as well as in the normal
contralat-
eral testis. Lesions were considered to be hypovascular if the concentration of visible blood vessels was less than the concentration in the surrounding normal testis or
in the normal vessels sidered tration tumor Pathologic
contralateral
testis
or
if no
were detected. Lesions were conto be hypervascular if the concenof visible vessels was greater in the than in the surrounding tissue. diagnosis
was
established
at
orchiectomy in all cases. Surgery was performed within 1 month of the color Doppler US examination in all cases (range, 1-29 days; mean, 7 days).
of the Mann-Whitney performed
on the
model QAD-1 unit was recorded on digital videotape and was reviewed retrospectively. The six examinations performed on the model Quantum 2000 unit were recorded on a color printer. The determination of hypoor hypervascularity was made in comparison with the vascularity
Yes
Hypervascular
Entire
on a model Quantum 2000 unit (Siemens Quantum, Issaquah, Wash). A 7.5-MHz, phased linear array transducer was employed in all cases. The slow-flow setting was used in all instances. Power and threshold settings were adjusted to maximize slow flow detection without in-
NA NA NA 8.4
25
performed
38.2
NA 1.0
Seminoma Mixedgerm cell tumor, inoma, teratoma
pulsed
ND ND ND Yes ND ND
Hypervascular
57
=
ND Yes No
sac
germ cell tumor,
25
No
.895 .883 NA NA NA .592 NA NA
Hypervascular
germ cell tumor, embryonal, choriocarcinoma,
32
not applicable. no pulsed Doppler performed,
.586
Hypervascular Hypervascular Hypervascular Hypervascular
testis testis
=
.617 NA
Hypovascular
Entire Entire
#{149} ND detected.
734
NA
Hypovascular
23 24
Note.-NA
troducing waveforms
Hypovascular
Hypervascular
Seminoma Mixed germ cell tumor, inoma, embryonal
sac,
4.0 x 5.0
Venous Flow*
Hypervascular Hypervascular Hypervascular
Lymphoma Seminoma Seminoma Seminoma
yolk
22
sem-
Seminoma Teratoma
34
3.3 x 1.9
sem-
cell
Embryonal Seminoma
9 10 11
21
Velocity (cm/sec)
Vascularity
Seminoma Mixed germ inoma,
3 4 5 6 7 8
Resistive Index
Cell Type
RESULTS The results from each individual patient are shown in the Table. Tumor cell types included 13 seminomas, eight mixed germ cell tumors, two teratomas, two lymphomas, one embryonal cell tumor, one leukemic
Yes
=
pulsed
performed
Doppler
infiltration, mor. Twenty than 1.6 cm vascular; six less than 1.6
ND and venous
flow
and one Leydig cell tuof 21 (95%) tumors more in diameter were hyperof seven (86%) tumors cm in diameter were hy-
povascular (Figs 1, 2). The single small hypervascular lesion was a 1.1-emdiameter seminoma (Fig 3). The large hypovascular tumor was also a seminoma. In our series the cell type of the tumor had no effect on the vaseularity of the lesion (Table). The distribution of the blood vessels within the tumor could be undisturbed following normal vascular planes (Fig 4), or the distribution could be random and disorganized (Fig 5).
The eluded choic
five
gray-scale 13 tumors with
cases
US findings that were
well-defined
the
lesions
margins.
involved
tire testis, which was diffusely choic. Seven cases included
echoic
and/or
cystic
inhypoe-
regions
In
the
en-
hypoehyper-
within
December
1992
Figure 7. Longitudinal view patient 12 with disseminated demonstrates a hypervascular
Figure 3. Longitudinal view of the testis of patient 3 demonstrates a hypoechoic, hypervascular, 1.1-cm seminoma (arrow). This is the only hypervascular tumor less than 1.6 cm in diameter.
lower sion size Figure 5. Transverse view of the left testis of patient 26 demonstrates a large hypoechoic hypervascular seminoma that replaces
the entire
testis.
The vessels
in this tumor
disorganized, with loss of normal pattern. Venous flow is demonstrated spectral analysis.
Figure 4. Longitudinal view patient 18 reveals a hypoechoic, lar, 2.5 x 3-cm seminoma (S
mal compressed around tumor
a normal vascular zation
The vessels in number
distribution planes. of these
within
No distortion vessels is seen.
ease
testes
the expected or disorgani-
findings
enlarged
bilaterally.
in the
gray-scale
In every
US ex-
amination and in the clinical history were believed to be most suggestive of testicular tumor. In one ease (patient 28) findings at gray-scale US and at physical exami-
Volume
185
Number
#{149}
3
this
color
than
the size
Doppler
US scan.
are
within the but maintain
inhomogeneous,
hypoechoic
was larger on
This le-
and its actual and at patho-
of
the tumor mass. The leukemie infiltrate caused the appearance of a unilateral homogeneous hypoechoic testis (Fig 6). One lymphoma had a focal hypoechoic mass with an ill-defined infiltrative margin (Fig 7), and one lymphoma caused the appearance of
diffusely
logic examination demonstrated
(arrow).
margins, US scanning
branching with
). A rim of nortissue (T) is seen
testicular
the tumor. are increased
of the testis hypervascu-
pole of the left testis had infiltrative at gray-scale
of the testis of lymphoma lesion in the
Figure 6. Transverse sonogram of the left testis of patient 25 with unilateral leukemic infiltration demonstrates an enlarged, markedly hypervascular testis. The distribution of the vessels within this testis are normal and are not distorted by the tumor.
nation suggested a tumor, while findings at color Doppler US were pro-
spectively interpreted with an inflammatory This occurred in a patient enlargement US scanning
vascularity of vessels
resolution apy
led
as consistent process (Fig 8).
early in our experience with painless testicular in whom color Doppler showed diffuse hyper-
with
a normal
within
the
following to the
correct
distribution
testis.
antibiotic diagnosis
Lack
of
therof tu-
Figure patient
8. Transverse 28 with a large
placed
the entire
pervascularity bution. On
testis
with the basis
the lack of vessel
view of the testis in seminoma that re-
reveals
marked
hy-
a normal vascular distriof our early experience,
distortion
led us to pro-
spectively suggest diffuse orchitis in this tient. We have subsequently seen several mors with a similar appearance at color Doppler US.
patu-
mor, and at surgery the testis was found to be diffusely enlarged with seminoma. Pulsed Doppler waveform analysis was performed in 14 cases. The resis-
tive
indexes
in the
tumor
vessels
that
were evaluated ranged from .476 to 1.0, with a mean of .70 (Figs 9, 10). Peak systolic flow velocities ranged from 8.4 to 64.9 em/see, with a mean value of 19.8 cm/sec. Venous flow was detected in eight cases.
Radiology
#{149} 735
DISCUSSION Testicular tumors are relatively uncommon neoplasms. A large percentage occur in young adults, in whom such tumors are the most common solid tumor. Testicular tumors are divided into two large categories: germ cell tumors and non-germ cell tumors. Germ cell tumors consist of seminomas (40%); embryonal cell with or without seminoma (25%); pure teratoma or teratoma with seminoma (5%-10%); teratocarcinoma with embryonal cell, yolk sac, and/or seminoma (25%); and choriocarcinoma with or without other cell types (1%-2%) (9). Non-germ cell tumors are uncommon except in patients older than 50 years, in whom malignant lymphoma is the most common lesion. Leukemia can also involve the testis, and the testis is a common site for initial recurrence in patients who have had chemotherapy-induced complete remission. Benign tumors compose less than 5% of testicular neopiasms and include Sertoli or Leydig cell tumors. Metastatic tumors are uncommon: most are diagnosed at autopsy in patients who died of diffuse metastatic disease (9). The diagnosis of testicular tumor is usually obvious clinically. Most are seen in patients who present with nontender masses. Frequently, episodes of mild trauma bring the patient’s attention to the scrotum, and he will palpate a mass that had been there previously but had not been appreciated. Occasionally, testicular tumors will present as acute pain or as a hydrocele (9). Some testicular himors are now being discovered mcidentally in patients undergoing US evaluation of infertility or other nonrelated problems. Since color Doppler US scanning is now being performed in many of these situations, it will become increasingly important to recognize testicular tumors at such scanning. Gray-scale US is useful in evaluating tumors to confirm that the palpable mass is intratesticular and to evaluate the contralateral testis, since a small percentage of tumors can occur bilaterally. Gray-scale findings in testicular tumors have been well doeumented (1,2). Our results indicate that findings at color Doppler US scanning of testicular tumors depend on the size of the lesion. Ninety-five percent of large lesions ( > 1.6 cm in diameter [n = 21]) were hypervascular compared with the normal testicular tissue, while six of seven tumors less than 1.6 cm in diameter were hypovascular. The cell 736
Radiology
#{149}
9. Figures
10. 9, 10.
(9) A longitudinal
shows a Doppler waveform sistance. (10) Longitudinal
view
of the
of low resistance,
type of the tumor had no correlation with the visible vascularity at color Doppler US scanning. The vessels within the tumor usually had a relatively normal distribution within expected vascular planes, as described previously by Middleton et al (3). Other tumors had very disorganized that
did
not
conform
to
these normal vascular planes. The size of the tumor and the type of cell did not affect the distribution of the blood vessels. The hypervascularity seen within tumors is not sonographically distinguishable from scribed appearance hypervascularity
the
of patient
19 with
from an intratesticular artery with a flow view of the testis of patient 26 with a large
noma demonstrates a flow pattern tratesticular arteries.
vasculature
testis
previously deof inflammatory at US (4). Early in
our experience one patient presented with an enlarged painless testis. Findings at gray-scale US and at physical examination suggested a tumor. Color Doppler US scanning showed hypervasculanty without obvious distortion of the normal vascular distribution. At the time, we thought this appearance at color Doppler scanning would most likely be caused by inflammation rather than by tumor. The patient did not improve with antibiotic therapy, and surgical exploration demonstrated a diffuse seminoma. We have subsequently seen several hypervas-
similar
mixed
germ
cell
tumor
pattern of very high hypervascular semi-
to the pattern
seen
re-
in normal
in-
cular tumors in which the normal distnbution of vessels has not been disturbed. Horstman et al (4) have also described focal orchitis as a cause of focal intratesticular hypervaseularity. This hypervascularity could potentially
be
confused
with
a tumor,
but
these eases the involved testis usually be tender and findings physical
examination
would
in
will at be
help-
ful to enable distinction. Performance of color scanning can be helpful
Doppler in eases
US of
lymphoma
in which
or leukemia
dis-
tinction
of abnormalities at gray-scale imaging can be subtle (10). Our cases of infiltrative lesions were all hypervascular,
and
the
findings
at color
Doppler US scanning were more striking than the changes seen at gray-scale scanning. This appearance at color Doppler scanning, however, still cannot be differentiated from the appearance of inflammatory changes without clinical correlation. Venous blood flow is not usually appreciated in the normal scrotum with color Doppler US scanning (3). The only exception to this rule is a case
in which
a large
transtesticular
artery is present, since this artery may be accompanied by a visible vein (5). Conspicuous venous flow was presDecember
1992
ent in the tumors of eight of our patients with neoplasms. We did not carefully
search
for
venous
flow
pro-
spectively so the true prevalence cannot be determined. Venous flow does occur in inflammatory lesions, so demonstration of such flow is a nonspecific finding. Normal intratesticular blood flow has a low resistance pattern similar to that of other parenchymal organs. The normal resistive index in intratesticular arteries is less than 0.7 (3,4). Our results indicate a large overlap in the resistive indexes of tumor vessels and the resistive indexes of inflamed and normal blood vessels (3,4). In five cases (patients 11, 19, 20, 21, 27) the resistive indexes measured in the tumor vessels were higher than any measured in 30 tests of healthy volunteers, as previously documented by Middleton et al (3). Some studies have shown a correlation between high peak systolic flow velocities and malignant tumors in the breast and liver (11-13). In eight patients the peak systolic velocity in the tumor vessels was greater than the maximum velocity measured in healthy
the
patients. We are systolic velocities compare with those
peak
mors testicles,
unsure how of the tuof inflamed
appreciable dex of the
we suspect that there overlap. The resistive five seminomas (range,
.476-.592;
mean,
cantly
but
lower
(P
.555)
G. Horstman,
Testicular with Color
MD
G. Leland
MD
Melson,
#{149}
Tumors: Doppler
William
D. Middleton,
#{149}
MD
Gerald
L. Andriole,
#{149}
MD
Findings US’
A study of 28 patients with surgically proved testicular tumors was performed to determine the appearance at color Doppler ultrasound (US) scanning. There was a general correlation of tumor size and vascularity. Twenty
of 21 (95%)
tumors
larger
than 1.6 cm were hypervascular. Six of seven (86%) tumors smaller than 1.6 cm were hypovascular. One small, 1.1-cm-diameter seminoma was hypervascular, and one 2.8-cm-diameter seminoma was hypovascular. The histologic findings of the tumor did not correlate with the vascularity of the lesion as seen at color Doppler US. Resistive indexes ranged from .476 to 1.0 (mean, 0.70). Peak systolic velocities ranged from 8.4 cm/sec to 64.9 cm/sec (mean, 9.8 cm/sec). Venous flow was detected in eight himors. The gray-scale findings, as well as history and physical examination findings, correctly suggested a neoplasm in all cases. The findings at color Doppler US were prospectively interpreted as indicative of neoplasm in 27 cases and as indicative of inflammation in one case. The authors conclude that color Doppler US scanning has only a limited role in the evaluation of testicular tumors. Index
terms:
neoplasms, trasound Radiology
Scrotum, US, 847.12984 #{149} Testis, 847.32 #{149} Testis, US, 847.12984 #{149} UI(US), Doppler studies, 847.12984 1992;
185:733-737
1.
2.
Figures
1, 2. (1) Transverse view of the testis of patient I demonstrates a hypoechoic, hypovascular, 4 x 5-mm seminoma (straight arrow). Normal centripedal arteries (curved arrow) and recurrent rami (arrowhead) are seen coursing through the testis. (2) Longitudinal view of the testis of patient 6 shows a hypovascular 1.4 x 1.0-cm Leydig cell tumor (T).
H
gray-scale (US) has
IGH-RESOLUTION
sonography
long
evaluate
ultrabeen
the standard of reference for the imaging evaluation of testicular masses. The appearance of neoplasms at US has
been
well
described
lar scintigraphy, phy,
and
(1,2).
computed
magnetic
The study
tomogra-
tients,
imaging
offer little additional information in imaging scrotal masses except in unusual situations. Color Doppler US is a relatively new modality in scrotal imaging
that
can
readily
display
nor-
mal testicular vascular anatomy (3). Many recent articles have shown the usefulness of color Doppler US in evaluation of acute scrotal disorders,
From the Mallinckrodt Institute of Radiology (W.G.H., G.L.M., W.D.M.) and the Department of Urologic Surgery (G.L.A.), Washington University
of Medicine, 510 S Kingshighway Blvd, St Louis, MO 631 10. Received May 12, 1992; revision requested June 26; revision received July 2; accepted July 6. Address reprint requests to G.L.M. RSNA, 1992
,.
School
in detail.
Since
performed in most pected tumors, the lesions
raphers. spectively surgically
must
be
US
patients
findings understood
scanning
with
proved
testicular
is
sus-
in these by sonog-
We prospectively and evaluated 28 patients
Doppler
METHODS
consisted
17-68
years
of 28 pa-
(mean,
36 years),
who were examined between March 1988 and March 1992. The presenting symptom was
a palpable
tients small
mass
the tumors lesions were
in 22 cases.
In six pa-
were nonpalpable: incidental findings
Two in
patients tal pain
being evaluated for chronic seroor infertility; three were metastatic
disease
(subsequently,
a small
in all patients.
any
patients
this tive
time US.
with were
Standard
verse
testicular
phased
preopera-
gray-scale
images
in trans-
testis
QAD-1 Issaquah,
were
unit
color performed
(Quantum
Wash).
ob-
7.5-MHz
All examinawith
Twenty-two
were
by using
transducers.
performed
aminations
planes
if
during
without
linear were
tumors
treated
in each
supine.
to
We do not know
testicular
and longitudinal
tamed tions
retrowith
tumors
AND
group
aged
formed
(4-8). To our knowledge, the appearance of testicular tumors at color Doppier US has not been previously deseribed
at color
tumor was visualized at US); and one was in a patient with acute scrotal pain. Grayscale US and color Doppler US were per-
especially in differentiating inflammatory conditions from testicular torsion
I
findings
MATERIALS
Testicu-
resonance
the
US.
the
patients
Doppler on
US exa model
Medical
Systems,
Six examinations
were
733
Doppler
Color
US Results
in 25 Patients
with Testicular
Tumors Peak Systolic
Patient
No.
Tumor Size (cm)
Age (y)
Patient
1 2
0.4 x 0.5 1.0 x 1.0
39 25
1.1 1.1 1.2 1.4 1.6 1.7
x x x x x x
0.85 1.0 1.3 1.0 1.6 1.5
cell tumor, embryonal
28 28 31 32 30 25
Seininoma
Seminoma
Leydig cell Teratoma Mixed germ cell tumor, inoma, embryonal
1.8 x 1.8 2.2 x 2.3 2.5 x 2.0
36 39 23
12 13 14 15 16 17
2.5 x 2.5
63
2.6 x 2.4 2.8 x 2.5
33
2.8 x 2.8 3.0 x 2.0 3.0 x2.4
32 35 21
18 19
3.0 x 2.5 3.2 x 3.0
34 26
Mixed
20
3.2 x 3.0
17
Mixed
NA
ND
NA
NA
ND
Hypervascular Hypovascular Hypovascular Hypovascular Hypovascular
.476 NA NA NA NA
Hypervascular
.563
10.7 NA NA NA NA 14.2 18.3 NA 19.8 33.2 30.0 NA NA NA
No ND ND ND ND Yes
sem-
Seminoma
embryonal,
germ cell
yolk teratoma tumor, sam-
Mixed
68
inoma, embryonal MIxed germ cell tumor, bryonal, yolk sac
emsem-
ND
Hypervascular
1.0
20.3
Yes
.912
47.2
No
Hypervascular
NA
NA
ND
Hypervascular
.588 NA
18.2 NA
No ND
Hypervascular
.512 .517
25.4 17.6
No
.531
19.2
Yes
.874 .696 NA
64.9 24.7 NA
Yes
testis
25
Leukemic
26
Entire
Seminoma
Entire
testis testis
42
27
63
Lymphoma
Hypervascular Hypervascular
28
Entire
testis
32
Seminoma
Hypervascular
color were
noise. Pulsed prospectively
Doppler studied
in
some cases to differentiate arterial from venous flow and to characterize arterial
flow. Resistive
indexes
were
prospectively
and retrospectively calculated whenever an arterial waveform was obtained. The resistive indexes of the seminomas and nonseminomatous germ cell tumors were
compared
by means
rank-sum
test.
Each US examination
#{149} Radiology
Doppler
infiltration
and no venous
performed
in the uninvolved
testis,
Hypervascular
portion
flow detected,
of the ipsilateral
as well as in the normal
contralat-
eral testis. Lesions were considered to be hypovascular if the concentration of visible blood vessels was less than the concentration in the surrounding normal testis or
in the normal vessels sidered tration tumor Pathologic
contralateral
testis
or
if no
were detected. Lesions were conto be hypervascular if the concenof visible vessels was greater in the than in the surrounding tissue. diagnosis
was
established
at
orchiectomy in all cases. Surgery was performed within 1 month of the color Doppler US examination in all cases (range, 1-29 days; mean, 7 days).
of the Mann-Whitney performed
on the
model QAD-1 unit was recorded on digital videotape and was reviewed retrospectively. The six examinations performed on the model Quantum 2000 unit were recorded on a color printer. The determination of hypoor hypervascularity was made in comparison with the vascularity
Yes
Hypervascular
Entire
on a model Quantum 2000 unit (Siemens Quantum, Issaquah, Wash). A 7.5-MHz, phased linear array transducer was employed in all cases. The slow-flow setting was used in all instances. Power and threshold settings were adjusted to maximize slow flow detection without in-
NA NA NA 8.4
25
performed
38.2
NA 1.0
Seminoma Mixedgerm cell tumor, inoma, teratoma
pulsed
ND ND ND Yes ND ND
Hypervascular
57
=
ND Yes No
sac
germ cell tumor,
25
No
.895 .883 NA NA NA .592 NA NA
Hypervascular
germ cell tumor, embryonal, choriocarcinoma,
32
not applicable. no pulsed Doppler performed,
.586
Hypervascular Hypervascular Hypervascular Hypervascular
testis testis
=
.617 NA
Hypovascular
Entire Entire
#{149} ND detected.
734
NA
Hypovascular
23 24
Note.-NA
troducing waveforms
Hypovascular
Hypervascular
Seminoma Mixed germ cell tumor, inoma, embryonal
sac,
4.0 x 5.0
Venous Flow*
Hypervascular Hypervascular Hypervascular
Lymphoma Seminoma Seminoma Seminoma
yolk
22
sem-
Seminoma Teratoma
34
3.3 x 1.9
sem-
cell
Embryonal Seminoma
9 10 11
21
Velocity (cm/sec)
Vascularity
Seminoma Mixed germ inoma,
3 4 5 6 7 8
Resistive Index
Cell Type
RESULTS The results from each individual patient are shown in the Table. Tumor cell types included 13 seminomas, eight mixed germ cell tumors, two teratomas, two lymphomas, one embryonal cell tumor, one leukemic
Yes
=
pulsed
performed
Doppler
infiltration, mor. Twenty than 1.6 cm vascular; six less than 1.6
ND and venous
flow
and one Leydig cell tuof 21 (95%) tumors more in diameter were hyperof seven (86%) tumors cm in diameter were hy-
povascular (Figs 1, 2). The single small hypervascular lesion was a 1.1-emdiameter seminoma (Fig 3). The large hypovascular tumor was also a seminoma. In our series the cell type of the tumor had no effect on the vaseularity of the lesion (Table). The distribution of the blood vessels within the tumor could be undisturbed following normal vascular planes (Fig 4), or the distribution could be random and disorganized (Fig 5).
The eluded choic
five
gray-scale 13 tumors with
cases
US findings that were
well-defined
the
lesions
margins.
involved
tire testis, which was diffusely choic. Seven cases included
echoic
and/or
cystic
inhypoe-
regions
In
the
en-
hypoehyper-
within
December
1992
Figure 7. Longitudinal view patient 12 with disseminated demonstrates a hypervascular
Figure 3. Longitudinal view of the testis of patient 3 demonstrates a hypoechoic, hypervascular, 1.1-cm seminoma (arrow). This is the only hypervascular tumor less than 1.6 cm in diameter.
lower sion size Figure 5. Transverse view of the left testis of patient 26 demonstrates a large hypoechoic hypervascular seminoma that replaces
the entire
testis.
The vessels
in this tumor
disorganized, with loss of normal pattern. Venous flow is demonstrated spectral analysis.
Figure 4. Longitudinal view patient 18 reveals a hypoechoic, lar, 2.5 x 3-cm seminoma (S
mal compressed around tumor
a normal vascular zation
The vessels in number
distribution planes. of these
within
No distortion vessels is seen.
ease
testes
the expected or disorgani-
findings
enlarged
bilaterally.
in the
gray-scale
In every
US ex-
amination and in the clinical history were believed to be most suggestive of testicular tumor. In one ease (patient 28) findings at gray-scale US and at physical exami-
Volume
185
Number
#{149}
3
this
color
than
the size
Doppler
US scan.
are
within the but maintain
inhomogeneous,
hypoechoic
was larger on
This le-
and its actual and at patho-
of
the tumor mass. The leukemie infiltrate caused the appearance of a unilateral homogeneous hypoechoic testis (Fig 6). One lymphoma had a focal hypoechoic mass with an ill-defined infiltrative margin (Fig 7), and one lymphoma caused the appearance of
diffusely
logic examination demonstrated
(arrow).
margins, US scanning
branching with
). A rim of nortissue (T) is seen
testicular
the tumor. are increased
of the testis hypervascu-
pole of the left testis had infiltrative at gray-scale
of the testis of lymphoma lesion in the
Figure 6. Transverse sonogram of the left testis of patient 25 with unilateral leukemic infiltration demonstrates an enlarged, markedly hypervascular testis. The distribution of the vessels within this testis are normal and are not distorted by the tumor.
nation suggested a tumor, while findings at color Doppler US were pro-
spectively interpreted with an inflammatory This occurred in a patient enlargement US scanning
vascularity of vessels
resolution apy
led
as consistent process (Fig 8).
early in our experience with painless testicular in whom color Doppler showed diffuse hyper-
with
a normal
within
the
following to the
correct
distribution
testis.
antibiotic diagnosis
Lack
of
therof tu-
Figure patient
8. Transverse 28 with a large
placed
the entire
pervascularity bution. On
testis
with the basis
the lack of vessel
view of the testis in seminoma that re-
reveals
marked
hy-
a normal vascular distriof our early experience,
distortion
led us to pro-
spectively suggest diffuse orchitis in this tient. We have subsequently seen several mors with a similar appearance at color Doppler US.
patu-
mor, and at surgery the testis was found to be diffusely enlarged with seminoma. Pulsed Doppler waveform analysis was performed in 14 cases. The resis-
tive
indexes
in the
tumor
vessels
that
were evaluated ranged from .476 to 1.0, with a mean of .70 (Figs 9, 10). Peak systolic flow velocities ranged from 8.4 to 64.9 em/see, with a mean value of 19.8 cm/sec. Venous flow was detected in eight cases.
Radiology
#{149} 735
DISCUSSION Testicular tumors are relatively uncommon neoplasms. A large percentage occur in young adults, in whom such tumors are the most common solid tumor. Testicular tumors are divided into two large categories: germ cell tumors and non-germ cell tumors. Germ cell tumors consist of seminomas (40%); embryonal cell with or without seminoma (25%); pure teratoma or teratoma with seminoma (5%-10%); teratocarcinoma with embryonal cell, yolk sac, and/or seminoma (25%); and choriocarcinoma with or without other cell types (1%-2%) (9). Non-germ cell tumors are uncommon except in patients older than 50 years, in whom malignant lymphoma is the most common lesion. Leukemia can also involve the testis, and the testis is a common site for initial recurrence in patients who have had chemotherapy-induced complete remission. Benign tumors compose less than 5% of testicular neopiasms and include Sertoli or Leydig cell tumors. Metastatic tumors are uncommon: most are diagnosed at autopsy in patients who died of diffuse metastatic disease (9). The diagnosis of testicular tumor is usually obvious clinically. Most are seen in patients who present with nontender masses. Frequently, episodes of mild trauma bring the patient’s attention to the scrotum, and he will palpate a mass that had been there previously but had not been appreciated. Occasionally, testicular tumors will present as acute pain or as a hydrocele (9). Some testicular himors are now being discovered mcidentally in patients undergoing US evaluation of infertility or other nonrelated problems. Since color Doppler US scanning is now being performed in many of these situations, it will become increasingly important to recognize testicular tumors at such scanning. Gray-scale US is useful in evaluating tumors to confirm that the palpable mass is intratesticular and to evaluate the contralateral testis, since a small percentage of tumors can occur bilaterally. Gray-scale findings in testicular tumors have been well doeumented (1,2). Our results indicate that findings at color Doppler US scanning of testicular tumors depend on the size of the lesion. Ninety-five percent of large lesions ( > 1.6 cm in diameter [n = 21]) were hypervascular compared with the normal testicular tissue, while six of seven tumors less than 1.6 cm in diameter were hypovascular. The cell 736
Radiology
#{149}
9. Figures
10. 9, 10.
(9) A longitudinal
shows a Doppler waveform sistance. (10) Longitudinal
view
of the
of low resistance,
type of the tumor had no correlation with the visible vascularity at color Doppler US scanning. The vessels within the tumor usually had a relatively normal distribution within expected vascular planes, as described previously by Middleton et al (3). Other tumors had very disorganized that
did
not
conform
to
these normal vascular planes. The size of the tumor and the type of cell did not affect the distribution of the blood vessels. The hypervascularity seen within tumors is not sonographically distinguishable from scribed appearance hypervascularity
the
of patient
19 with
from an intratesticular artery with a flow view of the testis of patient 26 with a large
noma demonstrates a flow pattern tratesticular arteries.
vasculature
testis
previously deof inflammatory at US (4). Early in
our experience one patient presented with an enlarged painless testis. Findings at gray-scale US and at physical examination suggested a tumor. Color Doppler US scanning showed hypervasculanty without obvious distortion of the normal vascular distribution. At the time, we thought this appearance at color Doppler scanning would most likely be caused by inflammation rather than by tumor. The patient did not improve with antibiotic therapy, and surgical exploration demonstrated a diffuse seminoma. We have subsequently seen several hypervas-
similar
mixed
germ
cell
tumor
pattern of very high hypervascular semi-
to the pattern
seen
re-
in normal
in-
cular tumors in which the normal distnbution of vessels has not been disturbed. Horstman et al (4) have also described focal orchitis as a cause of focal intratesticular hypervaseularity. This hypervascularity could potentially
be
confused
with
a tumor,
but
these eases the involved testis usually be tender and findings physical
examination
would
in
will at be
help-
ful to enable distinction. Performance of color scanning can be helpful
Doppler in eases
US of
lymphoma
in which
or leukemia
dis-
tinction
of abnormalities at gray-scale imaging can be subtle (10). Our cases of infiltrative lesions were all hypervascular,
and
the
findings
at color
Doppler US scanning were more striking than the changes seen at gray-scale scanning. This appearance at color Doppler scanning, however, still cannot be differentiated from the appearance of inflammatory changes without clinical correlation. Venous blood flow is not usually appreciated in the normal scrotum with color Doppler US scanning (3). The only exception to this rule is a case
in which
a large
transtesticular
artery is present, since this artery may be accompanied by a visible vein (5). Conspicuous venous flow was presDecember
1992
ent in the tumors of eight of our patients with neoplasms. We did not carefully
search
for
venous
flow
pro-
spectively so the true prevalence cannot be determined. Venous flow does occur in inflammatory lesions, so demonstration of such flow is a nonspecific finding. Normal intratesticular blood flow has a low resistance pattern similar to that of other parenchymal organs. The normal resistive index in intratesticular arteries is less than 0.7 (3,4). Our results indicate a large overlap in the resistive indexes of tumor vessels and the resistive indexes of inflamed and normal blood vessels (3,4). In five cases (patients 11, 19, 20, 21, 27) the resistive indexes measured in the tumor vessels were higher than any measured in 30 tests of healthy volunteers, as previously documented by Middleton et al (3). Some studies have shown a correlation between high peak systolic flow velocities and malignant tumors in the breast and liver (11-13). In eight patients the peak systolic velocity in the tumor vessels was greater than the maximum velocity measured in healthy
the
patients. We are systolic velocities compare with those
peak
mors testicles,
unsure how of the tuof inflamed
appreciable dex of the
we suspect that there overlap. The resistive five seminomas (range,
.476-.592;
mean,
cantly
but
lower
(P
.555)
