Athina C. Tsili

MRI in the Characterization and Local Staging of Testicular Neoplasms

OBJECTIVE The purpose of this study was to assess the role of MRI in the preoperative characterization and local staging of testicular neoplasms. SUBJECTS AND METHODS MRI was performed on 33 patients referred because a testicular mass had been detected clinically and sonographically. Both T1- and T2-weighted sequences were performed with a 1.5-T MRI unit. Gadolinium chelate was administered IV in all cases. We recorded the presence of a lesion and whether the histologic diagnosis of testicular malignancy could have been predicted on the basis of MRI features. For testicular neoplasms, local extension of disease was studied. The MRI findings were correlated with the surgical and histopathologic results. RESULTS Histologic examination revealed 36 intratesticular lesions, 28 (78%) of which were malignant and eight benign. Thirteen malignant testicular tumors (46%) were confined within the testis, 12 (43%) had invaded the testicular tunicae or epididymis, and three (11%) had invaded the spermatic cord. The sensitivity and specificity of MRI in differentiating benign from malignant intratesticular lesions were 100% (95% CI, 87.9-100%) and 87.5% (95% CI, 52.9-97.7%). The rate of correspondence between MRI and histologic diagnosis in the local staging of testicular tumors was 92.8% (26/28). CONCLUSION MRI is a good diagnostic tool for the evaluation of testicular disease. It is highly accurate in the preoperative characterization and local staging of testicular neoplasms.

MRI in the Histologic Characterization of Testicular Neoplasms

OBJECTIVE The purpose of our study was to investigate the potential role of MRI in the preoperative characterization of the histologic type of testicular tumors and, more specifically, to differentiate seminomatous from nonseminomatous testicular neoplasms. MATERIALS AND METHODS Twenty-one patients with histologically proven germ cell testicular tumors underwent MRI of the scrotum on a 1.5-T unit. T2- and T1-weighted sequences before and after i.v. administration of gadolinium chelate were performed. MRI studies were retrospectively reviewed by two radiologists and findings were correlated with the histopathologic diagnosis. An attempt was made to differentiate seminomatous from nonseminomatous testicular tumors on the basis of signal intensity and homogeneity of the lesions, presence of fibrovascular septa, tumor encapsulation, and patterns of contrast enhancement. Interobserver agreement was assessed using weighted kappa statistics. RESULTS MRI findings correctly characterized 19 (91%) of 21 testicular neoplasms (nine seminomatous and 10 nonseminomatous testicular tumors), with excellent interobserver agreement. The presence of an intratesticular lesion of predominantly low signal intensity on T2-weighted images, with septa enhancing more than tumor tissue after contrast material administration, was more suggestive for the diagnosis of a seminoma. Tumors that were markedly heterogeneous both on unenhanced and contrast-enhanced images were indicative of a nonseminomatous neoplasm. CONCLUSION Our study shows that MRI provides a credible preoperative differentiation of seminomatous from nonseminomatous testicular tumors, with excellent interobserver agreement.

Adnexal masses: Accuracy of detection and differentiation with multidetector computed tomography

OBJECTIVE The aim of our study was to evaluate the accuracy of multidetector computed tomography (MDCT) on a 16-row CT scanner in the detection and differentiation of adnexal masses. METHODS We prospectively examined 102 consecutive women with clinically or sonographically detected adnexal masses. Preoperative CT examination was performed, including scanning of the abdomen during the portal phase, using a detector collimation of 16 x 0.75 mm and a pitch of 1.2. Multiplanar reformatted images were evaluated for the presence of an adnexal mass and differentiation between benign and malignant ones, using the surgical and pathologic results as standard of reference. CT findings used to diagnose malignancy were: diameter greater than 4 cm, presence of masses bilaterally, cystic-solid mass, necrosis in a solid lesion, cystic lesion with thick, irregular walls or septa and/or with papillary projections. Presence of ascites, peritoneal metastases and lymphadenopathy was used to confirm malignancy. Multiple logistic regression analysis of the MDCT findings was performed to determine those more predictive of malignancy. RESULTS Histopathologic examination demonstrated 143 adnexal mass lesions, 96 (67%) of which were benign and 47 (33%) malignant. Multidetector CT detected 129 (90%) of the 143 adnexal masses, with an overall accuracy for the diagnosis of malignancy of 89.15%. The MDCT findings that found more predictive of malignancy were the presence of papillary projections in a cystic lesion, necrosis in solid mass and peritoneal metastases. CONCLUSION Multidetector computed tomography on a 16-row CT scanner proved accurate in the detection and characterization of adnexal masses.

Testicular microlithiasis imaging and follow-up: guidelines of the ESUR scrotal imaging subcommittee

AbstractObjectivesThe subcommittee on scrotal imaging, appointed by the board of the European Society of Urogenital Radiology (ESUR), have produced guidelines on imaging and follow-up in testicular microlithiasis (TML).MethodsThe authors and a superintendent university librarian independently performed a computer-assisted literature search of medical databases: MEDLINE and EMBASE. A further parallel literature search was made for the genetic conditions Klinefelter’s syndrome and McCune-Albright syndrome.ResultsProposed guidelines are: follow-up is not advised in patients with isolated TML in the absence of risk factors (see Key Points below); annual ultrasound (US) is advised for patients with risk factors, up to the age of 55; if TML is found with a testicular mass, urgent referral to a specialist centre is advised.ConclusionConsensus opinion of the scrotal subcommittee of the ESUR is that the presence of TML alone in the absence of other risk factors is not an indication for regular scrotal US, further US screening or biopsy. US is recommended in the follow-up of patients at risk, where risk factors other than microlithiasis are present. Risk factors are discussed and the literature and recommended guidelines are presented in this article.Key Points• Follow up advised only in patients with TML and additional risk factors. • Annual US advised for patients with risk factors up to age 55. • If TML is found with testicular mass, urgent specialist referral advised. • Risk factors – personal/ family history of GCT, maldescent, orchidopexy, testicular atrophy.

Diffusion-weighted MR imaging of normal and abnormal scrotum: preliminary results

Magnetic resonance (MR) imaging of the scrotum represents an important supplemental diagnostic tool in the evaluation of scrotal diseases. Diffusion-weighted (DW) MR imaging is a developing technique, proved to improve tissue characterization. We evaluated the feasibility and diagnostic performance of DW MR imaging in the detection and characterization of scrotal lesions. We retrospectively evaluated 31 scrotal lesions (23 intratesticular and 8 extratesticular) in 26 men. All MR examinations were performed on a 1.5-T unit, using a pelvic-phased array coil. DW sequences were obtained using a single shot, multislice spin echo planar diffusion pulse sequence and a b factor of 0 and 900 s mm(-2). The DW MR characteristics and the apparent diffusion coefficient (ADC) values of normal scrotal contents and scrotal diseases were evaluated. Comparison between the ADC values of normal scrotum, benign lesions and scrotal malignancies was performed. The accuracy of conventional sequences, DW images alone and DW imaging combined with conventional images in differentiating benign from malignant scrotal lesions was calculated. The ADC values of testicular malignancies were different from those of normal testis and benign intratesticular lesions, and the ADC values of benign extratesticular lesions from those of normal epididymis (P<0.05). The overall accuracy of conventional imaging, DW imaging alone and DW MR combined with conventional sequences in the characterization of intratesticular lesions was 91%, 87% and 100%, respectively. Our findings suggest that DW MR imaging and ADC values may provide valuable information in the diagnosis and characterization of scrotal diseases.

16-MDCT Cystoscopy in the Evaluation of Neoplasms of the Urinary Bladder

OBJECTIVE The purpose of this study was to evaluate the utility of 16-MDCT cystoscopy in the detection of urinary bladder neoplasms in a high-risk population. SUBJECTS AND METHODS Fifty patients who presented with hematuria and a recent diagnosis or a history of bladder carcinoma underwent CT cystoscopy. All patients were examined in the supine and prone positions after bladder distention with room air. A detector configuration of 16 x 0.75 mm and a pitch of 1.2 was used. Virtual images were obtained with volume-rendered algorithms. Transverse tomographic slices, multiplanar reformatted images, and virtual images were prospectively evaluated separately and in combination. Conventional cystoscopy was considered the standard of reference for assessing the efficacy of MDCT cystoscopy in the detection of urinary bladder tumors. RESULTS Fifty-five (96%) of 57 urinary bladder lesions recognized at conventional cystoscopy were detected with MDCT cystoscopy. The size of the lesions ranged from 0.3 to 9.7 cm in diameter, including 18 lesions with a diameter of 0.5 cm or less. Transverse, multiplanar reformatted, and virtual images proved complementary for lesion detection. CONCLUSION MDCT cystoscopy is an accurate technique for the detection of urinary bladder neoplasms in patients at high risk, yielding satisfactory results in the identification of lesions smaller than 0.5 cm.

Dynamic Contrast-Enhanced Subtraction MRI for Characterizing Intratesticular Mass Lesions

OBJECTIVE The objective of our study was to analyze the enhancement patterns of various intratesticular mass lesions at dynamic contrast-enhanced subtraction MRI and assess the value of the technique in distinguishing between benign and malignant lesions. MATERIALS AND METHODS We retrospectively evaluated the records and images of 44 consecutive men (11 benign and 16 malignant intratesticular lesions) who presented to the department of urology with a variety of clinical symptoms and were referred for imaging. Dynamic contrast-enhanced subtraction MRI was performed using a 3D fast-field echo sequence after the administration of paramagnetic contrast medium. Patients were divided into three groups according to the final diagnosis: benign intratesticular lesions, malignant intratesticular lesions, and normal testes. The patterns of contrast enhancement of both the normal testes and the intratesticular lesions were evaluated. Time-signal intensity plots were created and classified according to shape: Type I presented a linear increase of contrast enhancement throughout the examination, type II showed an initial upstroke followed by either a plateau or a gradual increase in the late contrast-enhanced phase, and type III presented an initial upstroke followed by gradual washout of the contrast medium. The relative percentages of peak height, maximum time, and mean slope were also calculated. RESULTS Normal testes enhanced homogeneously with a type I curve. Most benign intratesticular lesions showed inhomogeneous or homogeneous contrast enhancement and a type II curve. Testicular carcinomas showed heterogeneous contrast enhancement with a type III curve. The relative percentages of maximum time to peak proved the most important discriminating factor in differentiating malignant from benign intratesticular masses (p < 0.001). CONCLUSION Dynamic contrast-enhanced MRI may be used to distinguish between benign and malignant intratesticular mass lesions.

MR imaging of scrotum.

Magnetic resonance (MR) imaging of the scrotum has been used as a valuable supplemental diagnostic modality in evaluating scrotal pathology, mostly recommended in cases of inconclusive sonographic findings. Because of the advantages of the technique, MR imaging of the scrotum may provide valuable information in the detection and characterization of various scrotal diseases. The technique may accurately differentiate intratesticular from extratesticular mass lesions and provide important information in the preoperative characterization of the histologic nature of scrotal masses. An accurate estimation of the local extent of testicular carcinomas in patients for whom testis-sparing surgery is planned is possible.

Apparent diffusion coefficient values and dynamic contrast enhancement patterns in differentiating seminomas from nonseminomatous testicular neoplasms

INTRODUCTION The aim of this study is to investigate the role of apparent diffusion coefficient (ADC) values and dynamic contrast enhancement (DCE) patterns in differentiating seminomas from nonseminomatous germ cell tumors (NSGCTs). MATERIALS AND METHODS The MRI examinations of the scrotum of 26 men with histologically proven testicular GCTs were reviewed. DWI was performed in all patients, using a single shot, multi-slice spin-echo planar diffusion pulse sequence and b-values of 0 and 900 s/mm(2). Subtraction DCE-MRI was performed in 20 cases using a 3D fast-field echo sequence after gadolinium administration. Time-signal intensity curves were created and semi-quantitative parameters (peak enhancement, time to peak, wash-in and wash-out rate) were calculated. The Students t-test was used to compare the mean values of ADC, peak enhancement, time to peak, wash-in and wash-out rate between seminomas and NSGCTs. ROC analysis was also performed. RESULTS Histopathology disclosed the presence of 15 seminomas and 11 NSGCTs. The mean ± s.d. of ADC values (×10(-3)mm(2)/s) of seminomas (0.59 ± 0.009) were significantly lower than those of NSGCTs (0.90 ± 0.33) (P=0.01). The optimal ADC cut-off value was 0.68 × 10(-3)mm(2)/s. No differences between the two groups were observed for peak enhancement (P=0.18), time to peak (P=0.63) wash-in rate (P=0.32) and wash-out rate (P=0.18). CONCLUSIONS ADC values may be used to preoperatively differentiate seminomas from NSGCTs.

Apparent diffusion coefficient values of normal testis and variations with age

The usefulness of diffusion-weighted magnetic resonance imaging (DWI) in the evaluation of scrotal pathology has recently been reported. A standard reference of normal testicular apparent diffusion coefficient (ADC) values and their variations with age is necessary when interpreting normal testicular anatomy and pathology. We evaluated 147 normal testes using DWI, including 71 testes from 53 men aged 20–39 years (group 1), 67 testes from 42 men aged 40–69 years (group 2) and nine testes from six men older than 70 years (group 3). DWI was performed along the axial plane, using a single shot, multislice spin-echo planar diffusion pulse sequence and b-values of 0 and 900 s mm−2. The mean and standard deviation of the ADC values of normal testicular parenchyma were calculated for each age group separately. Analysis of variance (ANOVA) followed by post hoc analysis (Dunnett T3) was used for statistical purposes. The ADC values (× 10−3 mm2 s−1) of normal testicular tissue were different among age groups (group 1: 1.08 ± 0.13; group 2: 1.15 ± 0.15 and group 3: 1.31 ± 0.22). ANOVA revealed differences in mean ADC among age groups (F = 11.391, P < 0.001). Post hoc analysis showed differences between groups 1 and 2 (P = 0.008) and between groups 1 and 3 (P = 0.043), but not between groups 2 and 3 (P = 0.197). Our findings suggest that ADC values of normal testicular tissue increase with advancing age.