The testi-monial

On my ultrasound list today, patient X, returning for a follow-up, was recounting his ‘close shave’ from losing one of his testicles after a suspected lump was detected during an ultrasound examination at his local hospital when he had pain in the scrotum. He was initially listed for theatre for an orchiectomy and the patient was grateful that someone stopped that and referred him to us for a repeat scan, this time with an adjunct contrast-enhanced ultrasound, which showed the abnormality in his testicle was an infarct instead of a tumor (Figure 1), which improved on follow-up (Figure 2).

Incidentally detected testicular focal abnormality inevitably generates a great amount of anxiety, both for patients and doctors involved.

Why?

Ultrasound is good at picking up lesions. The problem is that, often, we do not know what they are, or what to do with them. While the old surgical dogma of ‘if in doubt, take it out’ does a good job in dealing with the uncertainty, it does appear to be an overly aggressive anxiety-relieving strategy, and not without consequence, as orchiectomy comes with associated endocrine, reproductive, and psychological impact.

It is worth noting that this problem is further exacerbated by the increased use of ultrasound for a variety of indications, which led to an increasing number of incidentally detected small focal testicular lesions. Many incidentally detected lesions are benign.

Even with the most beneficial of intentions, is scrotal ultrasound causing harm?

What could we do?

Which test tickles your fancy?

Although a variety of tools have been at the clinician’s disposal, the preoperative diagnoses of testicular masses remain uncertain in many cases. Tumor markers are often not raised in patients with malignant testicular tumors. MRI is considered a second-line tool for the characterization of focal testicular lesions; high cost, long study time, lack of standardization, and expertise are some of the drawbacks.

In most cases, ultrasound remains the primary diagnostic test to facilitate decision-making. Lack of flow on color Doppler (CD) increases the probability of a benign lesion but must be interpreted with caution as a substantial proportion of malignant lesions show no detectible vascularity.¹ Microflow techniques may increase sensitivity,² but the evidence is lacking for its value in assessing small testicular lesions. Imaging with contrast-enhanced ultrasound (CEUS) and elastography provides additional information.^3,4 CEUS is a particularly valuable technique. The unique value of CEUS is the unequivocal demonstration of the lack of vascularity likely to be encountered in benign lesions, such as an infarct,⁵ hematoma,⁶ or epidermoid cyst,⁷ allowing for “watchful waiting” with ultrasound.⁸ Contrast dynamics may help differentiate benign from malignant solid masses, but this technique is not yet sufficiently robust for routine clinical use.⁹ Strain elastography could potentially identify the “hard” lesion as more likely malignant and the “soft” lesion benign on strain elastography.¹⁰ Shear-wave elastography has been less extensively evaluated but may also show differences between benign and malignant testicular lesions.¹¹

I am not advocating that these ultrasound techniques are entirely diagnostic, but I am certainly suggesting that when combined with clinical and laboratory information, ultrasound technology is available for a more accurate assessment of the risk of malignancy. This may facilitate more desirable testis-sparing management options, such as ultrasound surveillance or testis-sparing surgery (TSS), to be considered, and avoid unnecessary orchidectomies.  

It is not nuts to suggest sparing the testicles.

The ball’s in your court.

References

1. Ma W, Sarasohn D, Zheng J, Vargas HA, Bach A. Causes of avascular hypoechoic testicular lesions detected at scrotal ultrasound: can they be considered benign? Am J Roentgenology 2017; 209:110–115.
2. Lee YS, Kim MJ, Han SW, et al. Superb microvascular imaging for the detection of parenchymal perfusion in normal and undescended testes in young children. Eur J Radiol 2016; 85:649–656.
3. Huang DY, Sidhu PS. Focal testicular lesions: colour Doppler ultrasound, contrast-enhanced ultrasound and tissue elastography as adjuvants to the diagnosis. Br J Radiol 2012; 85 Spec No 1:S41–S53.
4. Huang DY, Pesapane F, Rafailidis V, et al. The role of multiparametric ultrasound in the diagnosis of paediatric scrotal pathology. Br J Radiol 2020; 93(1110):20200063.
5. Zebari S, Huang DY, Wilkins CJ, Sidhu PS. Acute testicular segmental infarct following endovascular repair of a juxta-renal abdominal aortic aneurysm: case report and literature review. Urology 2019; 126:5–9.
6. Yusuf GT, Rafailidis V, Moore S, et al. The role of contrast-enhanced ultrasound (CEUS) in the evaluation of scrotal trauma: a review. Insights Imaging 2020; 11:68.
7. Patel K, Sellars ME, Clarke JL, Sidhu PS. Features of testicular epidermoid cysts on contrast-enhanced sonography and real-time tissue elastography. J Ultrasound Med 2012; 31:115–122.
8. Shah A, Lung PF, Clarke JL, Sellars ME, Sidhu PS. Re: New ultrasound techniques for imaging of the indeterminate testicular lesion may avoid surgery completely. Clin Radiol 2010; 65:496–497.
9. Pinto SPS, Huang DY, Dinesh AA, Sidhu PS, Ahmed K. A systematic review on the use of qualitative and quantitative contrast-enhanced ultrasound in diagnosing testicular abnormalities. Urology 2021; 154:16–23.
10. Fang C, Huang DY, Sidhu PS. Elastography of focal testicular lesions: current concepts and utility. Ultrasonography 2019; 38:302–310.

Roy C, de Marini P, Labani A, Leyendecker P, Ohana M. Shear-wave elastography of the testicle: potential role of the stiffness value in various common testicular diseases. Clin Radiol 2020; 75:560 e9–e17.

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Interested in learning more about contrast-enhanced ultrasound? Check out the following posts from the Scan:

• Sonographers and Contrast-Enhanced Ultrasound
• Should You Include CEUS and Elastography in Your Liver US Practice?
• A Quick Introduction to Subharmonic Imaging and Pressure Estimation