Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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Tubular Ectasia of Rete Testis TERMINOLOGY Synonyms • Dilated rete testis • Cystic transformation of rete testis IMAGING General Features • Best diagnostic clue ○ Variably sized network of dilated tubules near mediastinum testis with no flow on color Doppler • Location ○ Posterior near mediastinum testis ○ Frequently bilateral • Size ○ Can replace large portion of normal parenchyma ○ Variably sized cystic spaces • Morphology ○ Branching tubules converging at mediastinum testis ○ Characteristic appearance and location make it possible to distinguish this benign condition from malignancy Ultrasonographic Findings • Grayscale ultrasound ○ Longitudinal plane shows branching tubular structures along mediastinum – Dilated tubules create lace-like or "fishnet" appearance ○ Adjacent parenchyma is normal – Differentiates it from cystic malignant masses, which have abnormal rind of parenchyma ○ Associated ipsilateral spermatoceles are common – May also see intratesticular cysts • Color Doppler ○ Tubules are avascular and fluid filled, hence no color flow ○ Normal flow in adjacent testicular parenchyma MR Findings • MR performed for confirmation if cystic malignant neoplasm cannot be ruled out • T1 and proton density-weighted Images: Hypointense to testis • T2WI: Iso- to hyperintense to testis → nearly invisible ○ Malignant testicular neoplasms → solid portions hypointense on T2WI; have dark fibrous capsule Imaging Recommendations • Best imaging tool ○ High-resolution US (≥ 7.5 MHz) is imaging modality of choice • Protocol advice ○ Longitudinal plane shows morphology of tubules far better than transverse plane – Appears more mass-like and has greater likelihood of causing confusion when viewed in transverse plane ○ Always use color Doppler to look for areas of abnormal parenchymal flow DIFFERENTIAL DIAGNOSIS Testicular Carcinoma • Mixed germ cell tumors with teratomatous components will often have cystic areas • Does not form network of tubules • Surrounding parenchyma is abnormal ○ Will have abnormal flow on color Doppler Intratesticular Varicocele • Multiple intratesticular anechoic serpiginous tubules with characteristic color flow on Doppler, particularly during Valsalva maneuver • Will have associated extratesticular varicocele Testicular Infarct • Avascular hypoechoic mass, as sequelae of any previous vascular insult • Sharp, linear borders demarcate area PATHOLOGY General Features • Etiology ○ Partial or complete efferent ductule obstruction → ectasia → eventually cystic transformation ○ May be associated with epididymal obstruction due to inflammation or trauma • Associated abnormalities ○ Spermatocele ○ Epididymal cyst ○ Intratesticular cyst CLINICAL ISSUES Presentation • Most common signs/symptoms ○ Generally nonpalpable and asymptomatic ○ May be found when doing ultrasound for related issue, such as epididymal cyst or spermatocele Demographics • Age ○ Middle-aged to elderly men most commonly affected DIAGNOSTIC CHECKLIST Image Interpretation Pearls • Important to distinguish tubular ectasia from malignancy to prevent unnecessary orchiectomy SELECTED REFERENCES 1. Bhatt S et al: Imaging of non-neoplastic intratesticular masses. Diagn Interv Radiol. 2011 Mar;17(1):52-63. Epub 2010 Jun 30. Review. Erratum in: Diagn Interv Radiol. 17(4):388, 2011 2. Bhatt S et al: Sonography of benign intrascrotal lesions. Ultrasound Q. 22(2):121-36, 2006 3. Woodward PJ et al: From the archives of the AFIP: tumors and tumorlike lesions of the testis: radiologic-pathologic correlation. Radiographics. 22(1):189-216, 2002 4. Dogra VS et al: Benign intratesticular cystic lesions: US features. Radiographics. 21 Spec No:S273-81, 2001 5. Tartar VM et al: Tubular ectasia of the testicle: sonographic and MR imaging appearance. AJR Am J Roentgenol. 160(3):539-42, 1993 Diagnoses: Scrotum 695

Testicular Microlithiasis Diagnoses: Scrotum TERMINOLOGY • Microcalcifications composed of hydroxyapatite, located within the spermatic tubules IMAGING • On ultrasound, seen as discrete, punctate, nonshadowing echogenic foci scattered within testicular parenchyma • Majority are idiopathic; previous infection or trauma may also be responsible • Clusters of microliths may represent testicular tumors even when no soft tissue mass can be identified • Adjacent hypoechoic foci, if seen, could represent neoplasia • High resolution US (≥ 7.5 MHz) is modality of choice TOP DIFFERENTIAL DIAGNOSES • Scrotal pearls (scrotoliths) • Large-cell calcifying Sertoli cell tumor • Testicular granuloma KEY FACTS PATHOLOGY • Testicular neoplasia in 18-75%, intratubular germ cell neoplasia (IGCN), germ cell version of carcinoma in situ CLINICAL ISSUES • Presence of microlithiasis alone in absence of other risk factors is not indication for regular scrotal ultrasound, further sonographic screening or biopsy • US is recommended in follow-up of patients with risk factors, which includespersonal/family history of GCT, maldescent or undescended testes, orchidopexy, testicular atrophy (Left) Transverse grayscale ultrasound of bilateral testes demonstrates extensive microlithiasis. (Right) Sagittal color Doppler ultrasound of the right testis demonstrates a large hypoechoic mass in a background of microlithiasis ſt. Pathology confirmed a classic seminoma. (Left) Sagittal grayscale ultrasound of the right testis demonstrates multifocal hypoechoic masses in a background of microlithiasis with clustering at the superior pole . Pathology after orchiectomy confirmed multifocal seminoma. (Right) Sagittal grayscale ultrasound of the right testis demonstrates an enlarged testis infiltrated with a hypoechoic mass in a background of microlithiasis. Pathology after orchiectomy confirmed a seminoma 696

Testicular Microlithiasis<br />

Diagnoses: Scrotum<br />

TERMINOLOGY<br />

• Microcalcifications composed of hydroxyapatite, located<br />

within the spermatic tubules<br />

IMAGING<br />

• On ultrasound, seen as discrete, punctate, nonshadowing<br />

echogenic foci scattered within testicular parenchyma<br />

• Majority are idiopathic; previous infection or trauma may<br />

also be responsible<br />

• Clusters of microliths may represent testicular tumors even<br />

when no soft tissue mass can be identified<br />

• Adjacent hypoechoic foci, if seen, could represent neoplasia<br />

• High resolution US (≥ 7.5 MHz) is modality of choice<br />

TOP DIFFERENTIAL DIAGNOSES<br />

• Scrotal pearls (scrotoliths)<br />

• Large-cell calcifying Sertoli cell tumor<br />

• Testicular granuloma<br />

KEY FACTS<br />

PATHOLOGY<br />

• Testicular neoplasia in 18-75%, intratubular germ cell<br />

neoplasia (IGCN), germ cell version of carcinoma in situ<br />

CLINICAL ISSUES<br />

• Presence of microlithiasis alone in absence of other risk<br />

factors is not indication for regular scrotal ultrasound,<br />

further sonographic screening or biopsy<br />

• US is recommended in follow-up of patients with risk<br />

factors, which includespersonal/family history of GCT,<br />

maldescent or undescended testes, orchidopexy, testicular<br />

atrophy<br />

(Left) Transverse grayscale<br />

ultrasound of bilateral testes<br />

demonstrates extensive<br />

microlithiasis. (Right) Sagittal<br />

color Doppler ultrasound of<br />

the right testis demonstrates a<br />

large hypoechoic mass in a<br />

background of microlithiasis<br />

ſt. Pathology confirmed a<br />

classic seminoma.<br />

(Left) Sagittal grayscale<br />

ultrasound of the right testis<br />

demonstrates multifocal<br />

hypoechoic masses in a<br />

background of microlithiasis<br />

with clustering at the superior<br />

pole . Pathology after<br />

orchiectomy confirmed<br />

multifocal seminoma. (Right)<br />

Sagittal grayscale ultrasound<br />

of the right testis<br />

demonstrates an enlarged<br />

testis infiltrated with a<br />

hypoechoic mass in a<br />

background of microlithiasis.<br />

Pathology after orchiectomy<br />

confirmed a seminoma<br />

696

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