Testis carcinoma- imaging

Testis carcinoma- imaging

1. IMAGING IN TESTICULAR
CANCER
DEPT OF UROLOGY
GOVT ROYAPETTAH HOSPITAL AND KILPAUK MEDICAL COLLEGE
CHENNAI

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2. MODERATORS:
Professors:
•Prof. Dr. G. Sivasankar, M.S., M.Ch.,
•Prof. Dr. A. Senthilvel, M.S., M.Ch.,

Asst Professors:
•Dr. J. Sivabalan, M.S., M.Ch.,
•Dr. R. Bhargavi, M.S., M.Ch.,
•Dr. S. Raju, M.S., M.Ch.,
•Dr. K. Muthurathinam, M.S., M.Ch.,
•Dr. D. Tamilselvan, M.S., M.Ch.,
•Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai.
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3. WHY WE NEED IMAGING ????
•Diagnosis
•Staging
•Surveillance & Follow up
3
Dept of Urology, GRH and KMC, Chennai.

4. IMAGING MODALITIES
•ULTRASONOGRAPHY SCROTUM
•CECT ABDOMEN &PELVIS
•CT CHEST
•MRI ABDOMEN/LNP MRI
•CT/MRI BRAIN
•18 F-FDG PET/CT
4
Dept of Urology, GRH and KMC, Chennai.

5. DIAGNOSIS
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Dept of Urology, GRH and KMC, Chennai.

6. ULTRASONOGRAPHY
•USG Scrotum
Color Doppler
Contrast enhanced Usg
Sonoelastography
USG Abdomen and pelvis

6
Dept of Urology, GRH and KMC, Chennai.

7. ULTRASONOGRAPHY SCROTUM

High-frequency USG(7-18 MHz) with a linear-array
transducer with color doppler mode is the initial imaging
modality used in evaluation of a suspected testicular mass .
Accurate in localizing
lesions as intratesticular
or extratesticular, an
important distinction
since most intratesticular
masses are malignant .
Excellent in
differentiating benign
cysts from solid or
complex testicular
masses.
7
Dept of Urology, GRH and KMC, Chennai.

8. TECHNIQUE

•The examination should be carried out in a quiet room that is adequately
warm for patient comfort.
•The patient should be supine with the scrotum supported on a towel or on
the anterior thighs.
1.The patient should be draped in such a way as to hold the penis out of
the way and to ensure patient privacy.
2.Copious amounts of conducting gel should be used to provide a good
interface between the transducer and the scrotal skin.
3. Air trapping by scrotal hair results in unwanted artifacts..
8
Dept of Urology, GRH and KMC, Chennai.

9. •Excessive pressure results in
movement of testis or compression
of the testis.
•Change echogenicity and obscure
fine anatomic detail
• Alter volume measurements
Complete gentle
contact between skin
and transducer is
essential .
9
Dept of Urology, GRH and KMC, Chennai.

10. NORMAL USG SCROTUM
•Imaging :
Sagittal view
Transverse view •The sagittal view should proceed from the midline medially
and then laterally and from the midtransverse section of the
testis to the upper pole and the lower pole of the testis.
•The epididymis and entire scrotal contents should be imaged.
10
Dept of Urology, GRH and KMC, Chennai.

11. TESTIS :OVOID AND
HOMOGENOUS IN
ECHOGENICITY.

Testicular parernchyma:
Medium to low echogenicity
,finely granular appearance
which is slightly hypoechoic
/equal to when compared with
epididymal head.

11
Dept of Urology, GRH and KMC, Chennai.

12. MEDIASTINUM TESTIS :
Invagination of tunica
albuginea into body of the
testis.

Bright echogenic line within
testicular parenchyma
12
Dept of Urology, GRH and KMC, Chennai.

13. •Epididymis : Slightly sonoluscent located posterolateral to
testis.
•Rete testis : Network of tubules that carry sperm from
testis to epididymis.
•Normally not seen, when dilated appears as a focus of
anechoic tubular structures without a solid componemt
following the course of mediastinum.


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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

15. DOPPLER ULTRASONOGRAPHY

Doppler ultrasonography depends on the physical principle of
frequency shift when sound waves strike a moving object.
Sound waves of a certain frequency
are shifted or changed on the basis
of
1. the direction and velocity of
the moving object
2.the angle of insonation.
This phenomenon
allows for the
characterization of
motion, most
commonly the
motion of blood
through vessels.
15
Dept of Urology, GRH and KMC, Chennai.

16. COLOR DOPPLER
ULTRASONOGRAPHY

Allows for evaluation of the velocity and direction of motion.
The velocity of motion is designated by the intensity of the color.
The brighter the color, the greater the velocity.
A color map:
Blue to the motion away from the
transducer
Red to motion toward the transducer.
16
Dept of Urology, GRH and KMC, Chennai.

17. COLOR FLOW WITH SPECTRAL DISPLAY

Evaluate the pattern and velocity of blood flow
Displays the flow as a continuous waveform
The waveform provides information about
peripheral vascular resistance in the tissues.
The most commonly used index of these velocities
is the RESISTIVE INDEX.
RI=PSV-EDV /PSV
17
Dept of Urology, GRH and KMC, Chennai.

18. 18
Dept of Urology, GRH and KMC, Chennai.

19. POWER DOPPLER ULTRASONOGRAPHY
Assigns the amplitude of frequency change to a color map.

More sensitive mode
for detecting blood
flow.
Less affected by
backscatter waves
This mode does not permit evaluation of velocity
or direction of flow .


Power
Doppler is
less angle
dependent
than color
Doppler.
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

21. PULSED DOPPLER ULTRASOUND
Combines the velocity detection of continuous wave Doppler
with the range discrimination of a pulse echo system.
Short bursts of ultrasound are transmitted at regular intervals
The echoes are demodulated as they return
Pulses are received in sufficiently rapid succession
The output of the demodulator
Sequence of samples from which Doppler signal can be
synthesized.
21
Dept of Urology, GRH and KMC, Chennai.

22. COLOR FLOW & PULSED DOPPLER
OF TESTIS(NORMAL VALUES)

Low impdedance flow within parenchyma
Mean PSV (Peak systolic velocity) : 9.7-11 cm/sec
Mean EDV (End diastolic velocity) : 3.6-5 cm/sec
Normal value of RI :0.55-0.62
Measure of distal impedance
22
Dept of Urology, GRH and KMC, Chennai.

23. USG ABDOMEN &PELVIS



•If the testis is located within the pelvis /inguinal canal ,it
can be identified with confidence .
•Usually undescended testis smaller ,ovoid ,and slightly less
echognic than normally descended testis.


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Dept of Urology, GRH and KMC, Chennai.

24. SEMINOMA TESTIS
Well circumscribed hypoechoic mass
with marked internal vascularity

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Dept of Urology, GRH and KMC, Chennai.

25. NSGCT
Heteroechoic appearance
with cystic spaces and
calcification
ILL defined margin
25
Dept of Urology, GRH and KMC, Chennai.

26. LYMPHOMA
Hypoechoic and hypervascular
B/L
26
Dept of Urology, GRH and KMC, Chennai.

27. LEYDIG CELL TUMOR
Well circumscribed hypoechoic mass
with internal vascularity
27
Dept of Urology, GRH and KMC, Chennai.

28. MIMICS OF TESTICULAR
SEMINOMA
BENIGN
•Segmental infarction
•Testicular hematoma
•Orchitis
•Epidermoid cyst
•Adrenal rest
•Sarcoidosis
•Sex cord stromal tumors
•Splenogonadal fusion
MALIGNANT
•NSGCT
•Lymphoma
•Metastases
28
Dept of Urology, GRH and KMC, Chennai.

29. 29
Dept of Urology, GRH and KMC, Chennai.

30. SONOELASTOGRAPHY
The ability to evaluate the elasticity (compressibility and
displacement) of biologic tissues.
Essentially, it gives a representation, using color,
of the softness or hardness of the tissue of
interest.
Real-time elastography (RTE)
Shear wave elastography (SWE).
30
Dept of Urology, GRH and KMC, Chennai.

31. Young’s modulus or elasticity (E):
E=S/ e
E=Elasticity
S=Stress
e=Strain
E is larger in hard tissues
Lower in soft tissues.
Visually, the elasticity of a tissue is
represented by color spectrum.
The color given to hard lesions is determined by the
manufacturer of the equipment and can be set by the user
31
Dept of Urology, GRH and KMC, Chennai.

32. RTE



Deformation is induced by manually pressing on
the anatomy with the transducer and is measured
using ultrasonography.
32
Dept of Urology, GRH and KMC, Chennai.

33. Benefits
High spatial
resolution
It is a real-time
measurement
Demerits:
Qualitative
technique and
highly user
dependent.
Unable to
measure absolute
tissue stiffness .
33
Dept of Urology, GRH and KMC, Chennai.

34. SWE
Low-frequency (approximately 100 hz) pulses are rapidly transmitted
into the tissue
Induce a vibration in the tissue( in a single area or in a vertical plane
by rapidly altering focal depth)
The propagation velocity of the resultant transient shear waves
The viscoelastic properties of the tissues
34
Dept of Urology, GRH and KMC, Chennai.

35. LIMITATIONS OF SWE

Only a few millimeters of
propagation
Detection of shear wave propagation requires
very rapid acquisition speeds (pulse repetition
frequency is >5000 Hz), which may limit the
area of detection.
35
Dept of Urology, GRH and KMC, Chennai.

36. SONOELASTOGRAPHY (RTE) 36
Dept of Urology, GRH and KMC, Chennai.

37. SONOELASTOGRAPHY (SWE) 37
Dept of Urology, GRH and KMC, Chennai.

38. CONTRAST ENHANCED
ULTRASONOGRAPHY
Microbubbles used for enhancing the echogenicity of blood and tissue.
Microbubbles are distributed in the vascular system , create strong
echoes with harmonics when struck by sound waves.
The bubbles themselves are rapidly degraded by their interaction with
the sound waves.
Useful by enhancing the ability to recognize
areas of increased vasculature.
Rapid wash in & rapid wash out in case of
malignant lesions of testis.
38
Dept of Urology, GRH and KMC, Chennai.

39. SEMINOMA 39
Dept of Urology, GRH and KMC, Chennai.

40. LEYDIG CELL TUMOR 40
Dept of Urology, GRH and KMC, Chennai.

41. MAGNETIC RESONANCE IMAGING
SCROTUM
•TECHNIQUE:
1.5-T magnet is used for imaging the scrotum.
The patient is placed supine on the table feet first.
A folded towel is placed between the patient’s thighs to elevate the
scrotum to a horizontal plane.
The penis is taped to the abdominal wall out of the area of interest
A 12.5-cm circular multipurpose surface coil is centered over the
scrotum, with the bottom of the coil over the caudal tip of the scrotum.
Axial and coronal T1 and T2 weighted images are acquired
41
Dept of Urology, GRH and KMC, Chennai.

42. MRI SCROTUM

The normal testis is a
sharply demarcated
homogeneous oval structure

Low to intermediate signal
intensity on T1-weighted
images
High signal intensity on T2-
weighted images
42
Dept of Urology, GRH and KMC, Chennai.

43. THE TESTIS IS
SURROUNDED BY
THE TUNICA
ALBUGINEA, WHICH
HAS LOW T1 AND T2
SIGNAL INTENSITY

Mediastinum testis has
signal intensity similar to
that of the testis on T1-
weighted images .
Lower in signal intensity
than the testis on T2-
weighted image.
43
Dept of Urology, GRH and KMC, Chennai.

44. •The epididymis is slightly heterogeneous and isointense to the
testis on T1-weighted images.
•The epididymis is more clearly differentiated from the testis on
T2-weighted images because it has lower signal intensity than
the adjacent testis.
•Contrast material–enhanced images demonstrate
homogeneous enhancement of the testis and hyperintensity of
the epididymis relative to the testis.
•The scrotal wall is typically hypointense on T1- and T2-
weighted images
44
Dept of Urology, GRH and KMC, Chennai.

45. •Diffusion-weighted imaging is useful for detection of malignant
neoplasms.
•Is largely dependent on the extent of tissue cellularity, densely packed
neoplastic cells, and enlargement of nuclei, all of which are associated
with restricted diffusion owing to the reduced mobility of water
molecules.
•The mean ADC values for normal testicular parenchyma are in the
range of 1.08–1.31 10-3 mm2/sec, depending on patient age.
• Lower in malignant lesions than in benign lesions or normal tissue
45
Dept of Urology, GRH and KMC, Chennai.

46. SEMINOMA
TESTIS

Relatively homogeneous in
signal intensity.
Usually hypointense to normal
testis on T2-weighted images.
Fibrovascular septa may be
detected as bandlike areas of
low signal intensity on T1- and
T2-weighted images that
enhance to a greater degree
than the tumor.


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Dept of Urology, GRH and KMC, Chennai.

47. NSGCT
Nonseminomatous germ cell
tumors have heterogeneous
signal intensity .
Characteristics and
enhancement indicative of
necrosis and hemorrhage.
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Dept of Urology, GRH and KMC, Chennai.

48. LEYDIG CELL TUMOR
Isointense on T1-weighted images.
Hypointense on T2-weighted images
compared with the normal testis,
with marked homogeneous
enhancement.
Capsular high signal intensity on T2-
weighted images.
May have a high-signal-intensity
central scar on T2-weighted images.
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Dept of Urology, GRH and KMC, Chennai.

49. SERTOLI CELL TUMOR
Multiple nodules with
homogeneous intermediate
signal intensity on T1-
weighted images
High signal intensity on T2-
weighted images with rim
enhancement
49
Dept of Urology, GRH and KMC, Chennai.

50. LYMPHOMA
Low signal intensity on T1- and T2-
weighted images, with low-level
enhancement (less than the
normal testis).

Infiltrative pattern is common.

The diagnosis of lymphoma should
be considered if there is
involvement of both the testis and
the epididymis
.
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Dept of Urology, GRH and KMC, Chennai.

51. STAGING
51
Dept of Urology, GRH and KMC, Chennai.

52. IMAGING MODALITIES
•CECT ABDOMEN & PELVIS
•CT CHEST
•BRAIN CT/MRI(Symptomatic patient ,High B-HCG values)
•BONE SCAN (Symptomatic patient)

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Dept of Urology, GRH and KMC, Chennai.

53. CECT ABDOMEN AND PELVIS
CT with IV and oral contrast
administration is the reference standard
for evaluation of retroperitoneal
lymphadenopathy and the abdominal
viscera.

Staging of retroperitoneal disease
depends on nodal size.
Sensitivity :70-80%

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Dept of Urology, GRH and KMC, Chennai.

54. MALIGNANT LYMPH NODES ARE
IDENTIFIED BASED ON SIZE
CRITERIA, WITH MALIGNANT
NODES USUALLY CONSIDERED
TO BE 10 MM OR GREATER IN
DIAMETER.

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Dept of Urology, GRH and KMC, Chennai.

55. MRI ABDOMEN
High dose of radiation
during CT Abdomen
Relatively young age of
testicular cancer
patients
MRI as a potential
modality for
retroperitoneal lymph
node evaluation
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Dept of Urology, GRH and KMC, Chennai.

56. MRI ABDOMEN

CECT ABDOMEN/USG
Inconclusive
Allergy to contrast media
containing iodine


MRI IS AN OPTIONAL IMAGING
CURRENTLY NO USE IN STAGING OF CA TESTIS
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

58. LYMPHOTROPHIC NANOPARTICLE
ENHANCED MRI

Superparamagnetic iron
oxide nanoparticles
Small enough to pass
freely from the venous
system into the
medullary sinuses of
lymph nodes where
they are phagocytosed
by macrophages of the
reticuloendothelial
system.
58
Dept of Urology, GRH and KMC, Chennai.

59. 1. 24–36 hours after contrast administration because of the
specific bioavailability properties of the nanoparticles.
2. Individual nodes are typically compared with each other in
separate scans before and after contrast
Benign lymph nodes have normally functioning
macrophages that avidly take up these particles.

Macrophages in lymph nodes infiltrated with tumor
have dysfunctional phagocytosis.
59
Dept of Urology, GRH and KMC, Chennai.

60. The disparity in nanoparticle take-up
results in differential enhancement of
benign and malignant lymph nodes
on MRI
60
Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

62. CHEST IMAGING

Testicular cancer has propensity to spread to the mediastinal lymph
nodes after reaching the retroperitoneum.
1.Plays an important role in
initial staging .
2.CT chest is the most
sensitive evaluation.
1.Recommended in all
patients of testicular
cancer.
2.Upto 10% of patients
can present with
small subpeural nodes
not visible on chest
X- ray .
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

64. BRAIN IMAGING( CT/MRI BRAIN)

1. Neurologically symptomatic patient
2. Extensive pulmonary disease
3.High suspicion for brain metastases
4.Choriocarcinoma in orchidectomy specimen & persistently
elevated Beta HCG
64
Dept of Urology, GRH and KMC, Chennai.

65. PET/CT IMAGING
18 F-FDG PET/CT :
Not presently included in the initial staging of testicular malignancy due
to lack of evidence .
Recommended in follow
up of patients with
seminoma ( >8 wks post
last cycle of
chemotherapy) residual
retroperitoneal disease .
Not
recommended in
restaging of
patients with
NSGCT after
chemotherapy.
65
Dept of Urology, GRH and KMC, Chennai.

66. PET/CT IMAGING 66
Dept of Urology, GRH and KMC, Chennai.

67. SURVEILLANCE & FOLLOW UP
STAGE I
SEMINOMA
Y 1 Y 2-3 Y 4-5
ON SURVEILLANCE CECT ABD/PELVIS
3,6,12 MONTHLY
EVERY 12 MONTH AT 60 MONTHS
ADJUVANT CT/RT CECT
ABDOMEN/PELVIS
ANNUALLY AT 60 MONTHS
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Dept of Urology, GRH and KMC, Chennai.

68. 68
Dept of Urology, GRH and KMC, Chennai.

69. 69
Dept of Urology, GRH and KMC, Chennai.

70. 70
Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

72. EAU GUIDELINES
TEST RECOMMENDATION STRENGTH
RATING
Testis ultrasound
(bilateral)
All patients Strong
Abdominopelvic
computed
tomography (CT)
All patients

Strong

Chest CT All patients

Strong


72
Dept of Urology, GRH and KMC, Chennai.

73. EAU GUIDELINES
TEST RECOMMENDATION STRENGTH
RATING
Bone scan/MRI In case of symptoms Strong
BRAIN CT/MRI In case of symptoms and patients
with metastatic disease with
multiple lung metastases/high Beta
HCG values

Strong

73
Dept of Urology, GRH and KMC, Chennai.

74. THANK YOU
74
Dept of Urology, GRH and KMC, Chennai.