© 1990 S. Karger AG, Basel 0042-1138/90/0454-023752.75/0
Urol Int 1990;45:237-240
Ultrasonography of Testicular Tumors D. Marth, J. Scheidegger, U.E. Sluder Urologische Universitätsklinik, Inselspital, Bern, Schweiz
Key Words. Ultrasonic diagnosis • Testicular tumor • Seminoma
Abstract. From 1984 to 1989, 62 patients with palpable testicular tumor were examined with ultrasound before surgical exploration. The ultrasonographic morphology was compared with the histological diagnosis of the tumor. The radiologist’s interpretation regarding the type of tumor (seminoma versus nonseminomatous tumor) was correct in 70%. The typical sonography of the seminoma comprises homogeneous, hypoechogenic and sharply delineated masses, but nonseminomatous tumors are inhomogeneous, hypoechogenic, normoechogenic and hyperechogcnic masses with cysts and calcifications. The tumor stage could be predicted in precisely 44% of the seminomas and in only 8% of the nonseminomatous tumors. Nevertheless, the ultrasonogram of the testis may provide a false-positive tumor diagnosis. We conclude that ultrasonography may help us in the differential diagnosis of malignant tumors of the testis, but cannot replace surgical and histological exploration of the testis.
Patients and Methods Since the introduction of testicular ultrasonography at our hos pital in 1984, 62 patients were investigated sonographically because of a testicular tumor and subsequently operated on up to September 1989. All patients had a palpable tumor finding in the scrotum or the testis: this was verified sonographically. Sonography was carried out by the radiologist with the 7.5-mHz sector scanner, and docu mented. The sonographic morphology, the putative diagnosis by the
radiologist with regard to the tumor and the sonographic tumor stage (infiltration outside the organ in the ultrasonogram) were com pared with the macroscopic and histological tumor diagnosis and tumor stage after semicastration.
Results Sonographic Findings in Seminoma
The ultrasonogram in a typical seminoma (fig. 1) dis plays the following characteristics [1, 6, 8, 9]: (1) hypoechogenicity of the tumor compared to normal testicular parenchyma; (2) homogeneous sonographic pattern in the tumor; (3) round to oval form of the tumor with sharp delimitation from normal testicular parenchyma, and (4) multifocal seminoma involvement in a tumor (can be detected better in real-time testicular sonography investigation than on two-dimensional photodocumen tation).
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Ultrasonographic investigation of the scrotal contents enables definite location of the tumor in the correspond ing testes or delimitation of pathological changes in the region of the epididymis or the testicular capsule in 95% of cases [1-3, 5, 7, 10, 11]. In a retrospective analysis of our patients operated on because of a pathological finding on testicular palpation, we have compared the ultrasonographic morphology with the corresponding histological diagnosis.
Marth/Scheidegger/Studer
Fig. 1. Typical ultrasonographic appearance of a seminoma with hypoechogenicity of the tumor, homogeneous sonographic pattern in the tumor, round form and good delimitability from normal tes ticular parenchyma.
Sonographic Findings in Nonseminomatous Testicular Tumor
In nonseminomatous tumors (fig. 2), the ultrasono graphic morphology is very different from that of semi nomas. Histologically, these tumors are mainly em bryonic carcinoma or mixed testicular tumors. A further differentiation within the nonseminomatous tumors is hardly possible by sonography. The individual tumor regions in mixed tumors cannot be distinguished with ultrasound. The ultrasonographic morphology of these tumors shows the following characteristics [1, 5, 6, 8-11]: (1) inhomogeneous echo pattern in the tumor with hypoechogenic, normoechogenic and hyperechogenic areas; (2) calcifications and cysts in the tumor, and (3) irregular form with poor delimitability from normal testis (can be detected better in the real-time investigation in the pa tient than on the two-dimensional photodocumenta tion). Histologically Verified Seminoma
In the histological investigation, 25 of the 62 patients had a seminoma, 26 patients displayed a nonseminoma-
Fig. 2. Typical ultrasonographic appearance of a nonseminomatous tumor with inhomogeneous sonographic pattern in the tumor, cystic lesions and calcifications as well as poor delimitability from normal testicular tissue.
tous tumor. Histological workup of the testicular prepa ration did not reveal any tumor in 11 patients. In 16 (64%) of the 25 patients with seminoma, the characteristic seminoma alterations were described (n = 5, 20%) or the diagnosis ‘seminoma’ was made preoperatively by sonography (n = 11, 44%). In 9 (36%) cases with histologically pure seminoma, the tumor could be detected preoperatively, but a type diagnosis could not be made. In 11 (44%) of the 25 histologically verified seminomas, the occurrence of infiltration of the tumor into the testicular capsule or into the rete testis was already suspected on the basis of sonography. This putative diagnosis was confirmed by the histological workup. Histologically Verified Nonseminomatous Tumor
In 19 (73%) of the 26 patients with nonseminomatous tumor, the corresponding typical alterations were imaged preoperatively in the ultrasonogram, especially calcifications and cystic lesions (n = 3, 11 %), or a non seminomatous tumor was diagnosed (n =16, 62%). In 7 cases (27%), an ultrasonographic distinction into seminomatous or nonseminomatous tumor was not fea
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 5:44:20 AM
238
Ultrasonography of Testicular Tumors
Negative Tumor Histology
In 11 patients, the testes were exposed because of sus picion of a testicular tumor on pathological palpatory findings in the scrotal space. However, histological work up of the preparation did not reveal the presence of a malignant tumor. In 8 cases, there was no indication of a tumor in the sonography performed preoperatively. His tologically, these were mainly cases of epididymo-orchitis or benign alterations in the testicular capsules. On the other hand, the suspicion of a tumor was expressed in 3 cases on the basis of the ultrasonogram. However, the tumor could not be confirmed intraoperatively or histo logically. This corresponds to 5% incorrectly diagnosed testicular tumors in 62 testicular ultrasound investiga tions.
Discussion There is no doubt that ultrasonography is a diagnostic method suitable for diagnostic assignment of an unclear palpatory finding in the scrotum to the testis or the epi didymis or to the capsular testis [2-4], The sensitivity of sonography for tumor detection cannot be assessed on the basis of our patients, since this was a selected patient population all of whom displayed a palpable testicular finding. On the other hand, our figures show that a defi nite appraisal to ‘tumor’ or ‘no tumor’ is not always pos sible, as is proved by the three false-positive tumor diag noses. Testicular sonography in palpable testicular tumor enabled a type diagnosis with regard to seminomatous or nonseminomatous tumor in two thirds of the cases in our patient population. The analysis of our cases shows that a certain ‘learning curve’ is unmistakable in the establishment of the putative diagnosis by our radiolo gists. The finding was more descriptive at the beginning of the ultrasonography era. In recent years, the appraisal ‘seminoma/nonseminomatous tumor’ was mostly cor rect. The sonographic appearance with any cysts and calci fications as well as an inhomogeneous sonographic pat
tern in the tumor mostly allows identification to non seminomatous tumors. These characteristics may be at tributed inter alia to the frequent presence of secondary changes such as hemorrhages, necroses and calcium de posits. Such alterations are occasionally also found in seminoma, but are very much less pronounced and rarer in the latter. The interpretation of the ultrasonographic appearance in terms of the seminoma is more difficult (in contrast to nonseminomatous tumors), since the typ ical characteristics such as a homogeneous sonographic pattern, good delimitability and hypoechogenicity can not always be clearly discerned in the individual case. In seminomas, a monomorphous sonographic pattern predominates, which also enables better delimitability from normal tissue (testicular parenchyma, testicular capsule, rete testis), so that the local tumor stage can be appraised in certain cases (in our patients, in 44% of the histologically verified seminomas). A prediction of the local tumor stage is hardly possible in the nonseminoma tous tumors because of the poor delimitability from nor mal tissue (merely 8% correct specification of the tumor stage on the basis of ultrasonographic findings in our patients). Our findings roughly correspond to the results of Barozzi et al. [1], Nachtheim et al. [8], Schwerk et al. [9] and Wakat et al. [11] with regard to the ultrasonographic characteristics of the seminoma as compared to nonsem inomatous tumors. A differentiation between seminoma and nonseminomatous tumors appears to us to be possi ble in two thirds of the cases with palpable testicular tumor. A further differentiation is not possible because of the diversity of ultrasonographic morphology, which is also underscored by most authors. Ultrasonographic investigation thus cannot replace surgical exploration of the scrotal contents with an ap propriate histological investigation. Surgical exposure of the testes remains indispensable to the diagnosis of ma lignant testicular tumor.
References 1 Barozzi, L.; Dalla Rovere, S.; Ramini, R.; Tonti, R.; Bacchini P.: I tumori del testicolo. Radiologia med. 77: 663-667 (1989). 2 Brockmann, N.P.; Mass, R.; Lang, E.M.; Gonnermann, D.; Hart mann, M.; Klöppel, G.; Keller-Münch, G.: Real-time Sonogra phie intraskrotaler Raumforderungen. Digitale Bilddiagn. 6: 8692 (1986). 3 Caspo, Z.; Weissmüller, J.; Sigel, A.: Sonographie in der Früher kennung von nicht palpablen Zweit-Hodentumoren: eine pro spektive Studie. Urologe A 26: 334-338 (1987). 4 Caspo, Z.; Bomhof, C.; Giedl, J.: Implapable testicular tumors
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 5:44:20 AM
sible. The suspected infiltration of the tumor beyond the boundaries of the organ was consistent with the histolog ical tumor stage in only 2 patients (8%). In 15 patients (58%), no appraisal could be made with regard to the depth of infiltration in the ultrasonogram, and the sus pected infiltration proved not to be present in 9 patients (34%).
239
Marth/Scheidegger/Studer
240
6
7
8 9
10 Scott, R.F.; Bayliss, A.P.; Calder, J.F.; Garvie, W.H.H. Br. J. Urol. 58: 178 (1986). 11 Wakat, J.P.; Zwicker, C.; Claussen, C.: Skrotale Veränderungen im 3,5 MHz-Schallbild. Röntgenblätter 41: 304-309 (1988).
Dr. med. D. Marth Urologische Universitätsklinik Inselspital CH-3010 Bern (Switzerland)
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 5:44:20 AM
5
diagnosed by scrotal ultrasonography. Urology 32: 549-552 (1988). Haller, J.; Gritzmann, H.; Czembirek, H.: Der okkulte und der klinisch verdächtige Hodentumor. Radiologe 27: 113 (1987). Krähe, T.; Leipner, N.; Porst, H.: Echomorphologie der Hoden tumoren. Fortschr. Geb. Röntg Strahl. Nukl Med. 148: 609-614 (1988). Kratzik, C.; Kuber, W.; Donner, G.; Lunglmayr, G.; Frick, J.; Schmoller, H.J.: Impact of sonography on diagnosis of scrotal diseases. Eur. Urol. 14: 270-275 (1988). Nachtheim, D.A.; Scheible, W.F.; Gosink, B.: Ultrasonography of testis tumors. J. Urol. 129: 978-981 (1983). Schwerk, W.B.; Schwerk, W.N.; Rodeck, G.: Testicular tumors: prospective analysis of real-time US patterns and abdominal staging. Radiology 164: 369-374 (1987).
Urol Int 1990;45:237-240
Ultrasonography of Testicular Tumors D. Marth, J. Scheidegger, U.E. Sluder Urologische Universitätsklinik, Inselspital, Bern, Schweiz
Key Words. Ultrasonic diagnosis • Testicular tumor • Seminoma
Abstract. From 1984 to 1989, 62 patients with palpable testicular tumor were examined with ultrasound before surgical exploration. The ultrasonographic morphology was compared with the histological diagnosis of the tumor. The radiologist’s interpretation regarding the type of tumor (seminoma versus nonseminomatous tumor) was correct in 70%. The typical sonography of the seminoma comprises homogeneous, hypoechogenic and sharply delineated masses, but nonseminomatous tumors are inhomogeneous, hypoechogenic, normoechogenic and hyperechogcnic masses with cysts and calcifications. The tumor stage could be predicted in precisely 44% of the seminomas and in only 8% of the nonseminomatous tumors. Nevertheless, the ultrasonogram of the testis may provide a false-positive tumor diagnosis. We conclude that ultrasonography may help us in the differential diagnosis of malignant tumors of the testis, but cannot replace surgical and histological exploration of the testis.
Patients and Methods Since the introduction of testicular ultrasonography at our hos pital in 1984, 62 patients were investigated sonographically because of a testicular tumor and subsequently operated on up to September 1989. All patients had a palpable tumor finding in the scrotum or the testis: this was verified sonographically. Sonography was carried out by the radiologist with the 7.5-mHz sector scanner, and docu mented. The sonographic morphology, the putative diagnosis by the
radiologist with regard to the tumor and the sonographic tumor stage (infiltration outside the organ in the ultrasonogram) were com pared with the macroscopic and histological tumor diagnosis and tumor stage after semicastration.
Results Sonographic Findings in Seminoma
The ultrasonogram in a typical seminoma (fig. 1) dis plays the following characteristics [1, 6, 8, 9]: (1) hypoechogenicity of the tumor compared to normal testicular parenchyma; (2) homogeneous sonographic pattern in the tumor; (3) round to oval form of the tumor with sharp delimitation from normal testicular parenchyma, and (4) multifocal seminoma involvement in a tumor (can be detected better in real-time testicular sonography investigation than on two-dimensional photodocumen tation).
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 5:44:20 AM
Ultrasonographic investigation of the scrotal contents enables definite location of the tumor in the correspond ing testes or delimitation of pathological changes in the region of the epididymis or the testicular capsule in 95% of cases [1-3, 5, 7, 10, 11]. In a retrospective analysis of our patients operated on because of a pathological finding on testicular palpation, we have compared the ultrasonographic morphology with the corresponding histological diagnosis.
Marth/Scheidegger/Studer
Fig. 1. Typical ultrasonographic appearance of a seminoma with hypoechogenicity of the tumor, homogeneous sonographic pattern in the tumor, round form and good delimitability from normal tes ticular parenchyma.
Sonographic Findings in Nonseminomatous Testicular Tumor
In nonseminomatous tumors (fig. 2), the ultrasono graphic morphology is very different from that of semi nomas. Histologically, these tumors are mainly em bryonic carcinoma or mixed testicular tumors. A further differentiation within the nonseminomatous tumors is hardly possible by sonography. The individual tumor regions in mixed tumors cannot be distinguished with ultrasound. The ultrasonographic morphology of these tumors shows the following characteristics [1, 5, 6, 8-11]: (1) inhomogeneous echo pattern in the tumor with hypoechogenic, normoechogenic and hyperechogenic areas; (2) calcifications and cysts in the tumor, and (3) irregular form with poor delimitability from normal testis (can be detected better in the real-time investigation in the pa tient than on the two-dimensional photodocumenta tion). Histologically Verified Seminoma
In the histological investigation, 25 of the 62 patients had a seminoma, 26 patients displayed a nonseminoma-
Fig. 2. Typical ultrasonographic appearance of a nonseminomatous tumor with inhomogeneous sonographic pattern in the tumor, cystic lesions and calcifications as well as poor delimitability from normal testicular tissue.
tous tumor. Histological workup of the testicular prepa ration did not reveal any tumor in 11 patients. In 16 (64%) of the 25 patients with seminoma, the characteristic seminoma alterations were described (n = 5, 20%) or the diagnosis ‘seminoma’ was made preoperatively by sonography (n = 11, 44%). In 9 (36%) cases with histologically pure seminoma, the tumor could be detected preoperatively, but a type diagnosis could not be made. In 11 (44%) of the 25 histologically verified seminomas, the occurrence of infiltration of the tumor into the testicular capsule or into the rete testis was already suspected on the basis of sonography. This putative diagnosis was confirmed by the histological workup. Histologically Verified Nonseminomatous Tumor
In 19 (73%) of the 26 patients with nonseminomatous tumor, the corresponding typical alterations were imaged preoperatively in the ultrasonogram, especially calcifications and cystic lesions (n = 3, 11 %), or a non seminomatous tumor was diagnosed (n =16, 62%). In 7 cases (27%), an ultrasonographic distinction into seminomatous or nonseminomatous tumor was not fea
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 5:44:20 AM
238
Ultrasonography of Testicular Tumors
Negative Tumor Histology
In 11 patients, the testes were exposed because of sus picion of a testicular tumor on pathological palpatory findings in the scrotal space. However, histological work up of the preparation did not reveal the presence of a malignant tumor. In 8 cases, there was no indication of a tumor in the sonography performed preoperatively. His tologically, these were mainly cases of epididymo-orchitis or benign alterations in the testicular capsules. On the other hand, the suspicion of a tumor was expressed in 3 cases on the basis of the ultrasonogram. However, the tumor could not be confirmed intraoperatively or histo logically. This corresponds to 5% incorrectly diagnosed testicular tumors in 62 testicular ultrasound investiga tions.
Discussion There is no doubt that ultrasonography is a diagnostic method suitable for diagnostic assignment of an unclear palpatory finding in the scrotum to the testis or the epi didymis or to the capsular testis [2-4], The sensitivity of sonography for tumor detection cannot be assessed on the basis of our patients, since this was a selected patient population all of whom displayed a palpable testicular finding. On the other hand, our figures show that a defi nite appraisal to ‘tumor’ or ‘no tumor’ is not always pos sible, as is proved by the three false-positive tumor diag noses. Testicular sonography in palpable testicular tumor enabled a type diagnosis with regard to seminomatous or nonseminomatous tumor in two thirds of the cases in our patient population. The analysis of our cases shows that a certain ‘learning curve’ is unmistakable in the establishment of the putative diagnosis by our radiolo gists. The finding was more descriptive at the beginning of the ultrasonography era. In recent years, the appraisal ‘seminoma/nonseminomatous tumor’ was mostly cor rect. The sonographic appearance with any cysts and calci fications as well as an inhomogeneous sonographic pat
tern in the tumor mostly allows identification to non seminomatous tumors. These characteristics may be at tributed inter alia to the frequent presence of secondary changes such as hemorrhages, necroses and calcium de posits. Such alterations are occasionally also found in seminoma, but are very much less pronounced and rarer in the latter. The interpretation of the ultrasonographic appearance in terms of the seminoma is more difficult (in contrast to nonseminomatous tumors), since the typ ical characteristics such as a homogeneous sonographic pattern, good delimitability and hypoechogenicity can not always be clearly discerned in the individual case. In seminomas, a monomorphous sonographic pattern predominates, which also enables better delimitability from normal tissue (testicular parenchyma, testicular capsule, rete testis), so that the local tumor stage can be appraised in certain cases (in our patients, in 44% of the histologically verified seminomas). A prediction of the local tumor stage is hardly possible in the nonseminoma tous tumors because of the poor delimitability from nor mal tissue (merely 8% correct specification of the tumor stage on the basis of ultrasonographic findings in our patients). Our findings roughly correspond to the results of Barozzi et al. [1], Nachtheim et al. [8], Schwerk et al. [9] and Wakat et al. [11] with regard to the ultrasonographic characteristics of the seminoma as compared to nonsem inomatous tumors. A differentiation between seminoma and nonseminomatous tumors appears to us to be possi ble in two thirds of the cases with palpable testicular tumor. A further differentiation is not possible because of the diversity of ultrasonographic morphology, which is also underscored by most authors. Ultrasonographic investigation thus cannot replace surgical exploration of the scrotal contents with an ap propriate histological investigation. Surgical exposure of the testes remains indispensable to the diagnosis of ma lignant testicular tumor.
References 1 Barozzi, L.; Dalla Rovere, S.; Ramini, R.; Tonti, R.; Bacchini P.: I tumori del testicolo. Radiologia med. 77: 663-667 (1989). 2 Brockmann, N.P.; Mass, R.; Lang, E.M.; Gonnermann, D.; Hart mann, M.; Klöppel, G.; Keller-Münch, G.: Real-time Sonogra phie intraskrotaler Raumforderungen. Digitale Bilddiagn. 6: 8692 (1986). 3 Caspo, Z.; Weissmüller, J.; Sigel, A.: Sonographie in der Früher kennung von nicht palpablen Zweit-Hodentumoren: eine pro spektive Studie. Urologe A 26: 334-338 (1987). 4 Caspo, Z.; Bomhof, C.; Giedl, J.: Implapable testicular tumors
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 5:44:20 AM
sible. The suspected infiltration of the tumor beyond the boundaries of the organ was consistent with the histolog ical tumor stage in only 2 patients (8%). In 15 patients (58%), no appraisal could be made with regard to the depth of infiltration in the ultrasonogram, and the sus pected infiltration proved not to be present in 9 patients (34%).
239
Marth/Scheidegger/Studer
240
6
7
8 9
10 Scott, R.F.; Bayliss, A.P.; Calder, J.F.; Garvie, W.H.H. Br. J. Urol. 58: 178 (1986). 11 Wakat, J.P.; Zwicker, C.; Claussen, C.: Skrotale Veränderungen im 3,5 MHz-Schallbild. Röntgenblätter 41: 304-309 (1988).
Dr. med. D. Marth Urologische Universitätsklinik Inselspital CH-3010 Bern (Switzerland)
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 5:44:20 AM
5
diagnosed by scrotal ultrasonography. Urology 32: 549-552 (1988). Haller, J.; Gritzmann, H.; Czembirek, H.: Der okkulte und der klinisch verdächtige Hodentumor. Radiologe 27: 113 (1987). Krähe, T.; Leipner, N.; Porst, H.: Echomorphologie der Hoden tumoren. Fortschr. Geb. Röntg Strahl. Nukl Med. 148: 609-614 (1988). Kratzik, C.; Kuber, W.; Donner, G.; Lunglmayr, G.; Frick, J.; Schmoller, H.J.: Impact of sonography on diagnosis of scrotal diseases. Eur. Urol. 14: 270-275 (1988). Nachtheim, D.A.; Scheible, W.F.; Gosink, B.: Ultrasonography of testis tumors. J. Urol. 129: 978-981 (1983). Schwerk, W.B.; Schwerk, W.N.; Rodeck, G.: Testicular tumors: prospective analysis of real-time US patterns and abdominal staging. Radiology 164: 369-374 (1987).
