| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Genitourinary Imaging |
1 From the Departments of Radiology (A.M.B., L.E.H.) and Urology (J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021. From the 1998 RSNA scientific assembly. Received November 9, 1998; revision requested January 11, 1999; final revision received September 3; accepted September 15. Address correspondence to A.M.B. (e-mail: bacha@mskcc.org).
 |
Abstract |
|---|
 TOP Abstract IntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
|---|
MATERIALS AND METHODS: Two hundred thirty-five testicular US examinations were performed in 171 patients who previously underwent orchiectomy for testicular neoplasm. Abnormalities were identified in 28 patients. The abnormalities were described as masses, heterogeneous changes, or macrocalcification. US findings were correlated with histopathologic findings in specimens obtained at surgery in 18 patients; follow-up to determine clinical outcome was obtained from the review of medical records in the remaining 10 patients.
RESULTS: Testicular US revealed intratesticular mass in 15, heterogeneous changes in 11, and macrocalcification in two patients. Eighteen patients had histopathologic correlation; 13 had testicular cancer. At US, 10 of the 15 (67%) patients with a mass and only three of the 11 (27%) with heterogeneous changes had cancer. All 10 patients without surgical correlation had clinical follow-up of 2
–7 years (mean, 3.95 years), with no evidence of disease.
CONCLUSION: Intratesticular mass always is a concern, and heterogeneous changes are less worrisome, but in all patients, rigorous follow-up is recommended to rule out malignancy.
Index terms: Testis, abnormalities, 84.31, 84.32, 84.329 • Testis, neoplasms, 84.31, 84.32, 84.329 • Testis, US, 84.1298, 84.12983
|
Introduction |
|---|
|
TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
|---|
Ultrasonography (US) has been shown to be useful in demonstrating intratesticular disease (3–5). An intratesticular lesion should be considered malignant until proved otherwise. Testicular cancer may appear at US as an intratesticular, solid mass or as a diffusely heterogeneous echotexture within the testis, with cystic areas and with echogenic foci (6–8). In a patient who previously underwent orchiectomy for malignancy, an abnormal testis at US is of particular concern because of the documented increased incidence of a contralateral primary tumor (1,2) and because a second orchiectomy results in infertility and requires testosterone supplementation.
There is no consensus on the routine follow-up of patients with testicular cancer. A baseline computed tomographic (CT) scan of the abdomen and pelvis often is obtained after retroperitoneal lymph node dissection. Some clinicians obtain abdominal and pelvic CT scans annually; others do not. Routine testicular US follow-up is not performed, since the overall risk of developing a contralateral malignancy is too low to perform screening.
We undertook this study to correlate the clinical, US, and histopathologic findings in men who previously underwent orchiectomy for cancer and to categorize abnormal US results in the remaining testis.
|
MATERIALS AND METHODS |
|---|
|
TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
|---|
Patients were 28–64 years of age (mean, 40 years; median, 36 years). All had a testicular neoplasm at the time of the original orchiectomy, with the following pathologic diagnoses: nonseminomatous germ cell tumor (n = 19) or seminoma (n = 9) (Table 1). At the time of the initial orchiectomy, nine patients had stage I, 13 had stage II, and six had stage III disease (Table 1). In four patients, the initial orchiectomy was performed on a cryptorchid testis (one patient had bilateral undescended testes).
|
A sonographer performed the examinations, and one of the two dedicated sonologists (A.M.B. or L.E.H.), with 6 and 21 years of experience, confirmed the findings. The data were based on the original report and on retrospective review of the images by the two sonologists, who were blinded to the original US reports. The two sonologists independently reviewed the 28 abnormal testicular US images and classified them into one of three categories: mass, heterogeneous change, or macrocalcification. Heterogeneous change was defined as texture variation regardless of the size of the testis. Macrocalcification was defined as an echogenic focus at least 3 mm in diameter, with posterior shadowing. Microlithiasis also was noted. Microlithiasis was defined as microcalcifications, or pinpoint hyperechoic foci less than 3 mm in diameter, without posterior shadowing. Two disagreements were resolved by consensus.
The abnormal testis was on the right in 17 (61%) patients and on the left in 11 (39%) patients. Eighteen (64%) of the 28 patients underwent surgery 3 days to 20 weeks (mean, 5.3 weeks) after testicular US: 12 (67%) on the right and six (33%) on the left. Patients underwent surgical exploration if there were suspicious palpable masses, clearly elevated tumor marker levels, or suspicious US findings. Of the 18 patients who underwent surgery, 10 had a mass or firmness at physical examination, three had concomitant abdominal masses and/or adenopathy, three had US findings described as very suspicious and had recommendations for biopsy, one had increasing tumor marker levels, and one had an interval increase in the size of the mass at US. Orchiectomy was performed in 15 patients; testicular biopsy through an inguinal approach, in the remaining three patients.
One of the sonologists (A.M.B.) correlated the US findings with histopathologic findings in the 18 patients who underwent surgery. In patients who had second testicular primary tumors, the histopathologic findings and the intervals between the two cancers were determined.
The clinical outcome of the 10 patients who did not undergo surgery was determined with a review of medical records by one of the sonologists (A.M.B.). Eight patients who were being followed up had normal physical examination results and had normal tumor marker levels. Two other patients had palpable abnormalities. Surgery was recommended, but the patients refused, and their disease was managed with clinical and US follow-up. The 
2 test was performed.
|
RESULTS |
|---|
|
TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
|---|
2 test). Two patients had multiple intratesticular masses (one had cancer and the other had benign disease at pathologic examination). Two patients with intratesticular masses of 0.5 and 0.6 cm were observed. One was followed up for 6 years with 12 US examinations, without change (Fig 1). The other patient was followed up for 3 years with three follow-up US examinations and also demonstrated no change.
|
|
|
|
years later, also without change. The other patient with macrocalcification underwent six follow-up US examinations over 3 years, without change. Of 10 patients who incidentally had intratesticular microlithiasis at US, four (40%) had masses at US (two had benign abnormalities and two had cancer at histologic examination), and five (50%) had heterogeneous changes at US (three had cancer, one had benign abnormalities, and one did not undergo surgery). Five (63%) of the eight patients with microlithiasis who underwent surgery and five (50%) of the 10 with microlithiasis had a testicular malignancy. An additional patient, who had macrocalcification in addition to microcalcification, was followed up, without change.
Histopathologic Findings: Testicular Cancer
Testicular cancer was present in 13 (72%) of the 18 patients who underwent surgery, with histopathologic correlation. US demonstrated intratesticular masses in 10 (77%) patients and heterogeneous changes in three (23%) patients (Table 2). The diagnoses included seminoma (n = 11) and nonseminomatous germ cell tumor (n = 2) (Table 1). Nine patients had clinical stage I disease and four had stage III disease. In eight (62%) of the patients with contralateral testicular cancer, the histopathologic findings were identical to those of the original tumor: seminoma (n = 6) or nonseminomatous germ cell tumor (n = 2). Five (38%) patients with bilateral testicular tumors had different histopathologic findings (Table 3): The original histopathologic finding was nonseminomatous germ cell tumor, and the second finding was seminoma in all five patients. Three of the four patients with a removed cryptorchid testis, including the patient with bilateral cryptorchid testes, had seminoma in the remaining testis.
|
Histopathologic Findings: Benign Abnormalities
Benign abnormalities were present in five (28%) patients who underwent surgery. Histopathologic examination revealed scar (n = 3), Sertoli cell tumor (n = 1), and Leydig cell hyperplasia (n = 1). US demonstrated a mass in three (60%) patients (Fig 4) and heterogeneous changes in two (40%) patients. The patient with Leydig cell tumor had stable US findings for 5 months, with 3 repeat US examinations prior to surgery.
|
–7 years after initial diagnostic US (mean, 4 years; median, 3 years). These patients had either no change (n = 4) or improvement (n = 6) in their symptoms (scrotal pain and discomfort). Nine patients underwent repeat US 1–12 times (mean, four repeat examinations; median, three repeat examinations) 6 months to 7 years after the initial US (mean, 3 years; median, 3 years). Two patients had resolution of their heterogeneous changes at follow-up US, and the remainder were unchanged. No patient had any indication of recurrent disease or of a new primary tumor at follow-up US and/or clinical examination. |
DISCUSSION |
|---|
|
TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
|---|
US findings in this group of patients who previously underwent orchiectomy, with intratesticular abnormalities in the solitary testis, demonstrate that testicular cancer has a varied US appearance. US cannot always be used to differentiate benign abnormalities from malignant neoplasms in this important subset of patients; therefore, it is not the sole criterion in the decision to perform surgery but has to fit into the clinical picture. It serves as a critical adjunct in the armamentarium.
Patient cooperation also plays a large role in the decision to perform surgery. Nevertheless, the results of this study suggest that an intratesticular mass at US is associated with the highest risk of cancer (67%) in the solitary testicle. Heterogeneous change is associated with a risk of 27%. It is important that, in all patients, rigorous follow-up is performed.
The primary role of US is to help determine if there is an intra- versus extratesticular abnormality. A number of intratesticular benign entities have been described: dilated rete testes (9–11), scar, infarct, and benign neoplasm (7,12). US findings of the latter three are indistinguishable from cancer (7,12).
Cancer and benign entities can manifest at US as intratesticular masses or as heterogeneous changes. It is interesting that 10 (67%) of the 15 patients who had a mass at US had cancer and that only three (27%) of 11 with heterogeneous changes had cancer. The population (n = 18) in which we had histopathologic correlation was small; however, although a mass was the US finding with the highest predictive value for cancer, the likelihood that heterogeneous changes represented a testicular malignancy was not insignificant (27% overall). Only five (45%) of the 11 patients with heterogeneous changes underwent surgery, and only three (27%) of all the patients with heterogeneous changes at US had cancer. Benign masses were smaller overall than the malignant masses, but the sizes of the benign and malignant masses overlapped; therefore, this distinction was not clinically useful.
Bilateral testicular cancers can occur synchronously or metachronously. Synchronous tumors were reported to occur in two (22%) of the nine patients with bilateral testicular germ cell tumors (2). These results are similar to our findings; two (15%) of the 13 patients with bilateral testicular tumor in our study had synchronous disease.
The interval between the first and second metachronous tumors may vary widely, from less than 2 years to more than 20 years, with 78% (seven of nine) occurring within 10 years (2). Our results were similar; the interval between the first and second tumors was 1–18 years, with a median of 8 years. Histopathologic findings in the bilateral tumors have been reported as differing in approximately 50% of cases (2) versus in five of 13 (38%) cases in our study.
We observed that the stage distribution of the original cancer in the 28 patients versus in the 13 patients who had cancer in the remaining testis was different. In the original group, nine (32%) of the 28 patients with a testicular cancer had stage I disease. Of the 13 patients with a malignancy in the solitary testis and therefore bilateral testicular cancer, nine (69%) had stage I disease.
The distribution of clinical stage in the second primary tumor was different from that in the first for two reasons. First, the patients already had cancer and were in a clinical follow-up protocol; therefore, most lesions were detected early. Second, when bilateral disease was present, there was an overrepresentation of seminoma, which, by the nature of the disease, manifested at a lower stage than nonseminomatous germ cell tumor. The follow-up for patients with testicular cancer was the same regardless of stage. Although the majority of the patients' second testicular cancers were detected early, four (31%) of the 13 patients had second testicular malignancies that were stage III disease versus six (21%) of the 28 patients who had initial cancers. This suggests that either improved patient education or more vigorous follow-up is needed in certain instances.
Four of our patients had a history of cryptorchid testis. The undescended testis is at much higher risk than the normal testis to undergo malignant change, and seminoma is the most common histopathologic finding (7). It has been reported that 10% of all patients with testicular neoplasm (1) and 22%–50% of patients with bilateral testicular tumors have a history of cryptorchism (2). We found that three (23%) of 13 patients with bilateral testicular neoplasm had a history of cryptorchid testis. All three patients had seminoma at the second orchiectomy.
The association of testicular microlithiasis and testicular germ cell tumor has been described recently. Backus et al (13) reported that 17 of 42 (40%) patients with microlithiasis developed a germ cell tumor. However, all US in that series was performed because of a palpable mass. Hobarth et al (14) examined patients with bilateral testicular microlithiasis and found a testicular tumor in five (45%) of the 11 patients in their study population. In our study, 10 patients had intratesticular microlithiasis at US. Five (68%) of eight patients with microlithiasis who underwent surgery and five (50%) of the 10 with microlithiasis had a testicular malignancy. More studies are needed to examine the relationship of microlithiasis and malignancy.
A limitation of this study was that the follow-up in those patients who did not undergo surgery did not reach the mean for the development of testicular cancer in the remaining gonad; in our study, the mean was 9.4 years. However, there are patients who may develop testicular cancer early; at least those cancers would have been detected. It is important to note that without pathologic correlation, it really is not known whether US-depicted abnormalities are malignant. Another limitation was the retrospective nature of this study.
Intratesticular masses, heterogeneous changes, and macrocalcification were identified at US in patients after orchiectomy. Ten (67%) of the 15 patients with a mass at US had cancer, and only three (27%) of 11 patients with heterogeneous changes had cancer. Rigorous follow-up is recommended in all patients who do not undergo surgical exploration.
|
Footnotes |
|---|
|
References |
|---|
|
TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  A. M. Bach, L. E. Hann, W. Shi, C. S. Giess, H.-H. Yoo, J. Sheinfeld, and H. T. Thaler Is There an Increased Incidence of Contralateral Testicular Cancer in Patients with Intratesticular Microlithiasis? Am. J. Roentgenol., February 1, 2003; 180(2): 497 - 500. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| RADIOLOGY | RADIOGRAPHICS | RSNA JOURNALS ONLINE |
