Diagnostic Ultrasound - Abdomen and Pelvis

Testicular Lymphoma/Leukemia
TERMINOLOGY
Synonyms
• B-cell lymphoma of testis
Definitions
• Infiltrative neoplasm of testis in which tumor cells surround
and compress seminiferous tubules and normal testicular
vessels
IMAGING
General Features
• Best diagnostic clue
○ Bilateral, solid, hypoechoic, hypervascular
nodules/masses
○ Diffuse hypoechoic testis with hypervascularity
Ultrasonographic Findings
• Grayscale ultrasound
○ Unifocal or multifocal hypoechoic lesions
○ Diffuse enlarged testis with diffuse decreased
echogenicity
○ Striated pattern
○ Testicular shape not altered
• Color Doppler
○ Hypervascular lesions
○ Normal testicular vessels with straight course crossing
through lesions
Imaging Recommendations
• Best imaging tool
○ Ultrasound
• Protocol advice
○ Comparison of both testes to look for asymmetry in sizes
and echogenicity
Nuclear Medicine Findings
• Increased FDG uptake on PET
– Most commonly described in children with acute
lymphoblastic leukemia
• Associated abnormalities
○ May have enlarged lymph nodes in other parts of body
Gross Pathologic & Surgical Features
• Solid, tannish-white mass
• Lymphoma behaves similar to leukemia with abnormal cells
diffusely infiltrating interstitium with compression of
seminiferous tubules without causing their destruction
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Painless testicular mass/enlargement
• Other signs/symptoms
○ Weight loss, night sweats, fever, anorexia
Demographics
• Age
○ Lymphoma: 20-80 years
– Most common malignant tumor of testis in elderly
○ Leukemia: Seen in childhood
• Epidemiology
○ Lymphoma accounts for approximately 5% of all
testicular tumors
○ Most common bilateral testicular tumor
Natural History & Prognosis
• Primary lymphoma: 5-year survival rate of 12%
Treatment
• Stages IE and IIE: Orchidectomy
• Stage IIIE and IVE: Systemic chemotherapy using
cyclophosphamide, doxorubicin, vincristine, and
prednisolone
• Radiation in symptomatic and bulky deposits
• CNS prophylaxis should be considered
Diagnoses: Scrotum
DIFFERENTIAL DIAGNOSIS
Epididymoorchitis
• Enlarged and heterogeneous testis and epididymis
• Hypervascular
• Associated findings: Complex hydrocele, skin thickening
• Clinical findings of acute scrotum at time of presentation
Primary Testicular Neoplasm
• Solid or mixed solid-cystic discrete mass; ± calcifications
• May have increased vascularity
Granulomatous Orchitis (Tuberculosis)
• Multiple hypoechoic nodules
• Testis and epididymis involved
PATHOLOGY
General Features
• Etiology
○ Most commonly secondary lymphomatous involvement
of testis; rarely primary
○ Testis is "sanctuary organ": Blood gonad barrier limits
accumulation of chemotherapeutic agents
DIAGNOSTIC CHECKLIST
Consider
• Primary testicular neoplasm
• Orchitis if pain and fever present
Image Interpretation Pearls
• Bilateral, uni- or multifocal, or infiltrative hypoechoic
mass(es) with increased vascularity
• Maintained testicular contour
SELECTED REFERENCES
1. Bertolotto M et al: Grayscale and color Doppler features of testicular
lymphoma. J Ultrasound Med. 34(6):1139-45, 2015
2. Liu KL et al: Imaging diagnosis of testicular lymphoma. Abdom Imaging.
31(5):610-2, 2006
3. Mazzu D et al: Lymphoma and leukemia involving the testicles: findings on
gray-scale and color Doppler sonography. AJR Am J Roentgenol. 164(3):645-
7, 1995
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