eMedicine Specialties > Radiology > Genitourinary
Testicle, Malignant Tumors: Imaging
Updated: Mar 4, 2009
Radiography
Findings
Plain radiographs have no role in the initial diagnosis of testicular cancer. Metastasis to the chest is fairly common and often seen on screening chest radiographs. However, computed tomography (CT) scanning is more sensitive and specific for staging the disease.
Computed Tomography
Both computed tomography (CT) scanning and ultrasonography have been used to search for metastatic retroperitoneal lymphadenopathy, but CT scanning is more commonly used.
Findings
CT scan imaging is routinely performed as part of the initial staging process, but it is not sensitive or specific enough to be useful in evaluating undiagnosed testicular masses. Chest, abdominal, and pelvic CT scan studies are indicated for the evaluation of retroperitoneal and mediastinal metastases.
CT scanning of the chest is especially useful when mediastinal or parenchymal lung disease caused by testicular cancer is suspected. This modality or magnetic resonance imaging (MRI) is also indicated in patients with neurologic signs or symptoms.
The most common site of disease recurrence is the retroperitoneum; thus, CT scanning is the best tool to detect recurrence.
False Positives/Negatives
Lymphoma can be difficult to distinguish from metastatic testicular cancer. Use tissue sampling from the abnormal testicle to make this distinction.
Magnetic Resonance Imaging
Findings
MRI is not used as the initial modality to evaluate testicular masses.
Degree of Confidence
Increased signal intensity in the testicle is seen on T2-weighted images of testicular malignancies, but it is not specific for the disease.
Ultrasonography
Testicular infarction can mimic an infiltrative tumor.
The depiction here is classic for a seminoma. Testicular malignancies appear as a hypoechoic mass in the vast majority of cases.
This is a mixed germ cell tumor. Testicular cancers can be ill-defined and subtle.
This is a seminoma. Occasionally, testicular tumors occur at a more advanced stage. If the entire testicle is involved, comparison with the normal side may show diffusely decreased echogenicity. Sometimes, epididymal invasion can be noted on sonograms.
This is a seminoma. Sometimes epididymal invasion can be noted on sonograms.
Testicular epidermoids can mimic solid malignancies.
Findings
Testicular ultrasonography is used to determine the location of a palpable mass when testicular cancer is suspected. Generally, palpable extra-testicular lesions are benign. On the other hand, intratesticular masses, especially if they are palpable, are likely to be malignant and must be surgically explored. Therefore, ultrasonography is useful for localizing palpable abnormalities and to triage them for surgical repair when indicated.10
The examination is usually performed with a high-frequency linear transducer to compare the echotexture of the 2 testicles for areas of heterogeneity. Testicular cancers are hypoechoic relative to the surrounding parenchyma in about 95% of cases. Published findings suggest that seminomas are often more homogeneously hypoechoic and that nonseminomatous lesions are often more cystic, with interspersed areas of calcification.11,12
The tumor tissue type cannot be reliably differentiated solely by its ultrasonographic appearance. Commonly, seminomas are well defined within the tunica albuginea and homogeneously hypoechoic. Embryonal cell cancers typically are hypoechoic, with interspersed cystic components. Teratomas and choriocarcinomas are often heterogeneous with multiple internal calcifications present. Stromal cell tumors (eg, Leydig and Sertoli cell tumors) are generally well defined and hypoechoic, but calcifications are frequently found. Lymphoma and leukemia of the testicle generally present as an ill-defined, diffuse process of decreased echogenicity.
When multiple lesions are present, the differential diagnosis should be expanded to include metastatic processes, such as leukemia and lymphoma, and inflammatory processes, such as sarcoid. Testicular lymphoma can be difficult to diagnose when both testes are homogeneously hypoechoic.
Testicular microlithiasis (>5 or more microcalcifications within a testicle) results from concentric cores of calcification of intrasubstance collagen fibers. Case studies of patients with testicular tumors suggest a high rate of microlithiasis, but prospective evaluations of patients with microlithiasis have failed to demonstrate more than a minimal increase in the frequency of such tumors. Annual ultrasound screening of patients with microlithiasis has been suggested by some authors, but prospective studies have failed to demonstrate a positive cost-benefit ratio at this time. Azzopardi tumor is the name used for a presumed "spontaneously burned out" tumor, wherein malignant cells spontaneously necrose and calcify, perhaps related to outgrowing the blood supply.
Degree of Confidence
Although the specificity and sensitivity have not been reported, general consensus exists that an ultrasonographic finding of a solid or mixed cystic and solid intratesticular mass is an indication for surgical exploration.
False Positives/Negatives
False-negative results are most common in the infiltrative malignant processes. When a condition such as leukemia or lymphoma causes bilateral diffusely decreased echogenicity, the infiltrative malignant process can be difficult to recognize.
False-positive results are seen in a variety of conditions (see Images 1-12). Dilated rete testes can be masslike, and they can simulate a predominantly cystic mass. The imaging characteristics of epidermoid tumors can be indistinguishable from those of germ cell lesions. Cho et al report that the classic appearance for an epidermoid is a heterogeneous mass, possibly with concentric hyperechoic and hypoechoic layers forming a ring.13 The epidermoid is often avascular. An abscess or phlegmon of the testicle is hypoechoic and often associated with increased vascularity. Testicular infarction can present as ill-defined decreased echogenicity in a testicle, suggesting a diffusely infiltrative malignant process.
A troublesome scenario can occur when a patient presents with a history of trauma and the sonogram shows a hypoechoic focus presumed to be a hematoma. Distinguishing a hematoma from a testicular tumor can be impossible on the initial images. Because such tumors can be detected after incidental trauma, ultrasonographic follow-up of suspected hematomas is recommended to ensure their complete resolution.
More on Testicle, Malignant Tumors |
| Overview: Testicle, Malignant Tumors |
 Imaging: Testicle, Malignant Tumors |
| Follow-up: Testicle, Malignant Tumors |
| Multimedia: Testicle, Malignant Tumors |
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References
Katiyar RK, Singh A, Kumar D. Primary melanoma of testis. J Cancer Res Ther. Apr-Jun 2008;4(2):97-8. [Medline].
Hersmus R, de Leeuw BH, Wolffenbuttel KP, Drop SL, Oosterhuis JW, Cools M, et al. New insights into type II germ cell tumor pathogenesis based on studies of patients with various forms of disorders of sex development (DSD). Mol Cell Endocrinol. Sep 10 2008;291(1-2):1-10. [Medline].
Looijenga LH, de Munnik H, Oosterhuis JW. A molecular model for the development of germ cell cancer. Int J Cancer. Dec 10 1999;83 (6):809-14. [Medline].
Carmignani L, Bozzini G. Re: Increased incidence of testicular cancer in men presenting with infertility and abnormal semen analysis. J. D. Raman, C. F. Nobert and M. Goldstein [Letter]. J Urol. Apr 2006;175(4):1574; author reply, 1574.
Bach AM, Hann LE, Hadar O, et al. Testicular microlithiasis: what is its association with testicular cancer?. Radiology. Jul 2001;220(1):70-5. [Medline].
Peterson AC, Bauman JM, Light DE, et al. The prevalence of testicular microlithiasis in an asymptomatic population of men 18 to 35 years old. J Urol. Dec 2001;166(6):2061-4. [Medline].
McKiernan JM, Goluboff ET, Liberson GL, et al. Rising risk of testicular cancer by birth cohort in the United States from 1973 to 1995. J Urol. Aug 1999;162(2):361-3. [Medline].
Taskinen S, Fagerholm R, Aronniemi J, Rintala R, Taskinen M. Testicular tumors in children and adolescents. J Pediatr Urol. Apr 2008;4(2):134-7. [Medline].
Kao HW, Wu CJ, Chen CY, et al. Malignant tumor of testis imitating epididymo-orchitis. Arch Androl. Sep-Oct 2005;51(5):407-11.
Kravets FG, Cohen HL, Sheynkin Y, Sukkarieh T. Intraoperative sonographically guided needle localization of nonpalpable testicular tumors. AJR Am J Roentgenol. Jan 2006;186(1):141-3.
Carmignani L, Morabito A, Gadda F, et al. Prognostic parameters in adult impalpable ultrasonographic lesions of the testicle. J Urol. Sep 2005;174(3):1035-8.
Schwerk WB, Schwerk WN, Rodeck G. Testicular tumors: prospective analysis of real-time US patterns and abdominal staging. Radiology. Aug 1987;164(2):369-74. [Medline].
Cho JH, Chang JC, Park BH, et al. Sonographic and MR imaging findings of testicular epidermoid cysts [comment Dogra V. In. AJR Am J Roentgenol. 2002 Oct;179(4):1075; author reply 1075-6]. AJR Am J Roentgenol. Mar 2002;178(3):743-8. [Medline].
Labarthe P, Khedis M, Chevreau C, Mazerolles C, Thoulouzan M, Durand X, et al. [Management of pure teratoma of the testis in adult, results of a multicenter study over 15 years.]. Prog Urol. Dec 2008;18(13):1075-81. [Medline].
Soh E, Berman LH, Grant JW, Bullock N, Williams MV. Ultrasound-guided core-needle biopsy of the testis for focal indeterminate intratesticular lesions. Eur Radiol. Dec 2008;18(12):2990-6. [Medline].
Austoker J. Screening for ovarian, prostatic, and testicular cancers. Br Med J. Jul 30 1994;309(6950):315-20. [Medline].
Braga FJ, Arbex MA, Haddad J, Maes A. Bone scintigraphy in testicular tumors. Clin Nucl Med. Feb 2001;26(2):117-8. [Medline].
Derogee M, Bevers RF, Prins HJ, et al. Testicular microlithiasis, a premalignant condition: prevalence, histopathologic findings, and relation to testicular tumor. Urology. Jun 2001;57(6):1133-7. [Medline].
Dieckmann KP, Skakkebaek NE. Carcinoma in situ of the testis: review of biological and clinical features. Int J Cancer. Dec 10 1999;83(6):815-22. [Medline].
Doebler RW, Norbut AM. Localized testicular infarction masquerading as a testicular neoplasm. Urology. Aug 1999;54(2):366. [Medline].
Heidenreich A, Weissbach L, Holtl W, et al. Organ sparing surgery for malignant germ cell tumor of the testis. J Urol. Dec 2001;166(6):2161-5. [Medline].
Hurd DS, Olsen T. Cutaneous sarcoidosis presenting as a testicular mass. Cutis. Dec 2000;66(6):435-8. [Medline].
Middleton WD, Teefey SA, Santillan CS. Testicular microlithiasis: prospective analysis of prevalence and associated tumor. Radiology. Aug 2002;224(2):425-8. [Medline].
Resnick MI, Amis ES Jr, Bigongiari LR, et al. Staging of testicular malignancy. American College of Radiology. ACR appropriateness criteria. Radiology. Jun 2000;215 (suppl):741-6. [Medline].
Steinfeld AD. Testicular germ cell tumors: review of contemporary evaluation and management. Radiology. Jun 1990;175(3):603-6. [Medline].
von Eckardstein S, Tsakmakidis G, Kamischke A, et al. Sonographic testicular microlithiasis as an indicator of premalignant conditions in normal and infertile men. J Androl. Sep-Oct 2001;22(5):818-24. [Medline].
Further Reading
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Keywords
malignant testicular tumors, testicular germ cell tumors, germ cell tumors, GCTs, seminomas, nonseminomas, teratomas, teratocarcinomas, testicular metastases, primary testicular tumors, testicular cancer, embryonal cell tumors, choriocarcinomas, yolk sac tumors, endodermal sinus tumors, nongerminal testicular tumors, stromal Leydig cell tumors, Sertoli cell tumors
