Sonographic imaging of extra-testicular focal lesions: comparison of grey-scale, colour Doppler and contrast-enhanced ultrasound

Abstract

Extra-testicular lesions are usually benign but present with nonspecific grey-scale sonography findings. This study assesses conventional sonographic characteristics in the differentiation of extra-testicular tumoural from inflammatory lesions and whether contrast-enhanced ultrasound has a role. A retrospective database analysis was performed. All patients were examined by experienced sonographers employing standard techniques combining grey-scale, colour Doppler sonography and contrast-enhanced ultrasound. Features recorded were: clinical symptoms, size, location, echogenicity, colour Doppler sonography and contrast-enhanced ultrasound enhancement. Vascularity on colour Doppler sonography and contrast-enhanced ultrasound was graded and compared. The lesions were classified as tumoural or inflammatory. The Chi-square test was used to analyse the sonographic patterns and kappa coefficient to measure the agreement between colour Doppler sonography and contrast-enhanced ultrasound. A total of 30 lesions were reviewed (median diameter 12 mm, range 5-80 mm, median age 52 years, range 18-86 years), including 13/30 tumoural and 17/30 inflammatory lesions. Lesions were hypoechoic (n = 12), isoechoic (n = 6), hyperechoic (n = 2) or mixed (n = 10). Grey-scale characteristics of tumoural vs. inflammatory lesions differed significantly (P = 0.026). On colour Doppler sonography, lesions had no vessels (n = 16), 2-3 vessels (n = 10) and ≥4 vessels (n = 4). On contrast-enhanced ultrasound, lesions showed no vascularity (n = 17), perfusion similar to testis (n = 7) and higher (n = 6). All abscesses identified (n = 9) showed no vascularity on both colour Doppler sonography and contrast-enhanced ultrasound. There was good agreement between these techniques in evaluating vascularity (κ = 0.719) and no significant difference between colour Doppler sonography and contrast-enhanced ultrasound of tumoural vs. inflammatory lesions (P > 0.05). The grey-scale appearances of extra-testicular lesions are essential for characterisation. Colour Doppler sonography and contrast-enhanced ultrasound findings are not useful in that respect. Contrast-enhanced ultrasound is excellent in establishing absence of vascularity.

Multiparametric ultrasound findings in a patient with polyorchidism

“…It can thus readily differentiate structures with no perfusion, like calculi or epidermoid cysts, from ectopic testicular or splenic parenchyma and neoplasias characterized by a different perfusion pattern. 5,16–18 In our case report, we were able to demonstrate the similar enhancement pattern of an incidentally found extratesticular mass to the ipsilateral testis, helping to establish the diagnosis of polyorchidism. The diagnosis was also supported by the identification of a “transmediastinal artery” within the extratesticular lesion.…”

The EFSUMB Guidelines and Recommendations for the Clinical Practice of Elastography in Non-Hepatic Applications: Update 2018

“…However, these findings have not been confirmed in recent studies, with specificities between 25.0 % and 37.5 % in differentiating benign from malignant lesions [375 -377]. A number of case series detailing the use of SE and SR (some in combination with contrast-enhanced ultrasound) have described the findings in Leydig cell tumors [378], epidermoid cysts, hematoma, lymphoma, focal infarction, capillary hemangioma, adrenal rest cells [379 -384] and in extra-testicular lesions [385], without comparison between the findings of these different lesions.…”

The EFSUMB Guidelines and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound (CEUS) in Non-Hepatic Applications: Update 2017 (Long Version)

“…However, since both infarction and intratesticular abscess lack internal vessels, absolute differentiation remains difficult. CEUS may be able to determine the development of an abscess at an earlier stage, or the complete extent of a large abscess, and allow for prompt treatment [70,71,76,83].…”

“…Quantification of CEUS of testicular tumors remains a research tool. There is limited use of CEUS in intrascrotal extratesticular focal lesions, with no evidence regarding the usefulness for the differentiation of solid lesions [83].…”