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Soft tissue radiography of the testes
Clin. Radiol. (1978) 29, 685-689 SOFT TISSUE RADIOGRAPHY OF THE TESTES B. J.
LOVEDAY and J. L. PRICE
From The Royal Surrey County Hospital, Guildford A technique of soft tissue radiography of the testes is presented. The normal radio logical appearances are described, and also the radiological features seen in 75 patients with testicular lesions. Of these, 18 patients had malignant neoplasms and 57 patients had benign conditions. Testicular tumours appeared as very radio-opaque, quite sharply defined shadows. Benign conditions were less radio-opaque and often had ill-defined margins. A diagnostic accuracy of 88% was achieved in differentiating between testicular tumours and benign conditions.
INTRODUCTION Traditionally the diagnosis of scrotal swellings is made by taking a careful history, followed by a meticulous clinical examination, including transillumination of the scrotum. In most cases a confident clinical diagnosis can be made on this alone, but some patients present difficult diagnostic problems. Although a testicular tumour usually presents as a painless swelling of one testicle, the spectrum of clinical presentation is quite wide. In a series of 93 patients with testicular tumours, Irene Cade (1973) reported that pain was a presenting symptom in 21% of seminomas and 35% of teratomas. Fever is occasionally present, and the rapidly growing anaplastic teratoma may give a clinical picture very similar to epididymo-orchitis. About 5-10% of testicular tumours are associated with a secondary hydrocoele (Collins and Pugh, 1964). The technique of soft tissue radiography has been developed in an endeavour to aid the diagnosis of these difficult cases. The primary aim is to differentiate between benign conditions and testicular tumours. TECHNIQUE The technique previously described (Price and Loveday, 1975) has been developed directly from that used for mammography. A single Medichrome film is backed by a fine grain high definition screen, and these are vacuum packed in a thin opaque polyethylene envelope. A GEC Mammostand is used with a Machlett H.D. 50 molybdenum tube, which has a 0.8 mm focal spot. The exposure factors used are 30 kVp, 12-15 mA at 70 cm FFD. The skin radiation dose measured by thermoluminescent dosimetry, is less than 0.25 rad/exposure. The patient is usually positioned in the supine or semi-reclining position on a trolley next to the X-ray machine, with the scrotum resting upon the film in
its vacuum pack. The film holder is removed and the X-ray tube is angled approximately 15~° towards the patient's feet. A certain degree of ingenuity is often required in positioning the patient to overcome variations in build and physique. Oblique views are sometimes appropriate but usually one AP view is adequate. MATERIAL
A total of 85 patients have undergone testicular radiography. The first 10 cases have not been included in the series for assessment of diagnostic accuracy, because of the diagnostic uncertainty associated with a new technique. The diagnoses were consistently wrong until it was realised that malignant tumours were sharply defined. Of the 75 remaining cases, there were 57 benign conditions and 18 testicular tumours. The age range of all patients was from 16 years to 84 years, with an age range of 2 3 46 for testicular tumours. The distribution of the benign conditions is shown in Table 1. The 10 normal patients all presented with scrotal pain, which resolved without specific treatment and the normal X-ray report offered some reassurance to the clinician. Some patients had multiple scrotal pathology. Table 1 -
Benign conditions
Normal Epididymal cysts Chronic infection Hydrocoeles Varicocoeles Torsion Acute abscess TB epididymitis Absent testicle Benign hypertrophy Hydatid of Morgani
10 16 5 9 8 2 1 1 3 1 1
686
CLINICAL RADIOLOGY
The tumours discovered included 11 seminomas, two teratomas and five with mixed teratomas and seminomas. R A D I O L O G I C A L APPEARANCES N o r m a l . - The radiological appearances o f the normal scrotum have been obtained b y studying the 10 normal cases and by observation of the unaffected side of all the other cases. The healthy side o f the scrotum acts as a convenient and accurate control, for it is subject to the same radiographic variables as the pathological side. The normal testes (Fig. 1) are approximately 4 - 5 cm long, are of medium, similar, radio-opacity and both have clearly defined medial borders. The scrotal skin, median septum and fascial planes can be identified and at the upper poles the epididymis and veins m a y be seen.
Fig. 1 - Normal - both testes are the same size and radioopacity. Testicular T u m o u r s . - The appearances of seminomas, teratomas and mixed turnours are similar. There is usually a marked increase in the radioopacity o f the testis compared with the healthy side. The testis is commonly enlarged and its medial margins clearly defined (Fig. 2). The presence o f a secondary hydrocoele produces blurring o f the margins but the density is greater than that seen with a benign hydrocoele.
Fig. 2 - Left mixed tumour - the left testis is more radioopaque than the right and has a well defined margin.
Fig. 3 - Left seminoma - this patient had undescended testes in childhood. An orchidectomy was performed on the right and an ordiopexy on the left. A seminoma developed in this remaining testis.
One of the teratomas in the series showed fine calcification within the tumour (Fig. 4). Professor Diard of the University of Bordeaux has kindly provided us with the scrotal X-rays of two young boys. One with a teratoma, which shows fine calcification within the tumour similar in appearance to our case. The other patient was a 7-year-old b o y with a Leydig cell tumour o f the testes. This shows spectacular lace-like calcification throughout the tumour (Fig. 5).
T a b l e 2 - R a d i o l o g i e a l appearances
Size Density Margin Calcification
Turnouts
Benign conditions
Testis enlarged Very radio-opaque Well defined testicular margin Fine calcification within testes (teratomas and Leydig cell tumours)
Scrotum enlarged Moderately radio-opaque Indistinct testicular margin Coarse plaques of calcification in scrotal wall and epididymis Varicocoeles have a characteristic appearance
SOFT TISSUE RADIOGRAPHY
OF THE TESTES
687
Fig. 4 - Left teratoma - the left testis is enlarged, very radio-opaque and contains some fine calcification. Fig. 6 - Right inflamed epididymal cyst - the right side of the scrotum is enlarged and slightly more radio-opaque than the left. The margins of the testes are indistinct.
Fig. 5 - Leydig cell tumour - marked lace-like calcification Fig. 7 - Left epididymal cyst - the cyst is separate from the Within the tumour. (X-ray kindly supplied by Professor testis. Slight varicocoele is also seen on the left. Francois Diard). Epididymal C y s t s . - Epididymal cysts appear as a generaiised enlargement o f one side o f the scrotum. The radio-opacity is either the same or slightly increased compared with the healthy side. In the larger cysts the margins o f the testes are indistinct and merge with the scrotal wails (Fig. 6). We were unable to explain this finding initially; but at operation it has been found that some low grade inflammation was associated with the cysts in very many of the cases. A few smaller cysts were clearly defined but were separate from the testis (Fig. 7). Epididymal cysts into which there has been haemorrhage m a y be slightly more radio-opaque. V a r i e o c o e l e s . - Radiology was a definite help in the management of one case (Fig. 8). The patient presented with an enlarged and tense scrotum which felt solid and a testicular tumour was considered as a possible diagnosis. Radiologically the testis appeared normal. It was surrounded by numerous serpiginous shadows representing varicose veins o f the pampiniform plexus.
Fig. 8 - Right varicocoele - the normal right testis is surrounded by the serpiginous shadows of the varicocoele. A testicular tumour was suspected clinically. I n f e c t i o n . - It was found that all inflammatory conditions give a similar picture o f a generalised increase in size o f the affected side of the scrotum and a moderate increase in radio-opacity. The most characteristic feature, however, is the blurring of the tissue planes which is seen in acute epididymo-
688
CLINICAL RADIOLOGY
orchitis, acute scrotal abscesses and tuberculous epididymitis (Fig. 9). H y d r o c o e l e s . - The affected side of thb scrotum often shows a marked increase in size and there is an increase in radio-opacity, but with hydrocoeles this is not as marked as with testicular tumours, and the outline of the t~stis cannot be identified (Fig. 113). Torsion o f the t e s t i s . - Radiographs of acute torsion show anatomical distortion of the pedicle with a normal size testis and some blurring oedema. In t h e late stages with chronic torsion or infarction o f the testis, the testis becomes small, dense and fibrotic with a sharply defined margin. C a l c i f i c a t i o n . - Many o f the operative specimens have been X-rayed; but although confirming the site o f calcification this has not provided additional information. Calcification occurs in b o t h benign and malignant disease. Plaques of calcification may commonly occur in the wall of the scrotum. In chronic infective granulomas clusters of fine calcification are demonstrable within the scrotal sac, but are separate from the testes (Fig. 12). A benign type o f calcification has been seen in the b o d y of the epididymis clearly delineating its convoluted duct system. Fine punctate or filigree calcification m a y be seen in teratomas and Leydig cell tumours and this is confirmed on specimen radiography. This type of calcification has not yet been observed in seminomas.
Fig. 1 0 - Right hydrocoele - the hydrocoele is associated with an inguinal hernia. The outline of the right testis cannot be defined.
Fig. 11 - Left epididymal calcification. Some calcification is also seen in the wall of the right SCrOtum. The testes are normal.
DIAGNOSTIC ACCURACY Although in some cases it was possible to make a definitive diagnosis, the objective has been to distinguish between testicular tumours and benign conditions, and an assessment of diagnostic accuracy has been made on these factors (Table 3). Of the 75 cases in the series, a correct diagnosis was made in 66 patients when compared with the patient's final clinical or histological diagnosis. Fig. 12 - Left chronic granuloma - the calcification is in the granuloma. The testes are normal, but a testicular tumour was suspected clinically. Table 3 - Diagnostic accuracy
Benign condition o f testicular tumours
Fig. 9 - Right tuberculous epididymitis - the typical blurred outline of infection is shown. The calcification was found to be in the right epididymis and the left scrotal wall.
Total in series Correct diagnosis for benign and malignant False negative (malignant tumours) False positive Percentage accuracy for benign and malignant disease
75 66 2 7 88
SOFT TISSUE
RADIOGRAPHY
There were seven false positive and two false negative reports for tumour diagnosis. This gives an overall diagnostic accuracy o f 88% for b o t h benign and malignant disease. Four o f the false positive cases came to operation; three showed chronic infective granulomas and one was normal. The other three were not operated upon, but settled after conservative treatment. The radiological diagnosis in these cases was equivocal and caution was expressed with such terms as, 'the presence o f a testicular turnout cannot be entirely excluded'. One false negative case was given an inconclusive report, and in retrospect this would probably be reported as a tumour, with our present experience. The other false negative case was disappointing as a confident diagnosis of normality was made, and in retrospect the radiological appearances are still normal. Fortunately the clinical features were sufficiently suspicious to warrant operation and a small seminoma was found.
OF THE TESTES
689
screens with Medichrome films enables the radiation dose to the gonads to be kept to a very low level, certainly under 0.25 rad per exposure. Analysis of our figures shows that the radiological features are being established with some degree of consistency. The clinicians who have referred the cases feel that soft tissue radiography o f the testes forms an extension o f the clinical examination, and when allied with the full clinical picture is a useful aid to diagnosis and management. It is suggested that these early results justify continued development and assessment o f the technique. Acknowledgements. - We are grateful to Mr T. P. N. Jenkins, FRCS, who originally suggested the approach. Also to Mr P. D. Butler for his technical skills in producing the films. Our thanks to Professor Diard for allowing us to use two of his cases and for his encouragement. REFERENCES
DISCUSSION Soft tissue radiography of the testes has not been attempted before. The introduction o f low kVp apparatus and suitable film for mammography now enables satisfactory soft tissue radiography o f the testes to be obtained. The use of high definition
50
Cade, Irene (1973). The clinical picture and management of testicular tumours. ClinicalRadiology, 24, 385-391. Collins, D. H. & Pugh, R. C. B. (1974). The pathology of testieular tumours. British Journal of Urology, 36 Suppl. to volume 36. Price, J. L. & Loveday, B. J. L. (1975). Preliminary communication. Soft tissue radiography of the testicles. British Journal of Radiology, 48, 179-180.
LOVEDAY and J. L. PRICE
From The Royal Surrey County Hospital, Guildford A technique of soft tissue radiography of the testes is presented. The normal radio logical appearances are described, and also the radiological features seen in 75 patients with testicular lesions. Of these, 18 patients had malignant neoplasms and 57 patients had benign conditions. Testicular tumours appeared as very radio-opaque, quite sharply defined shadows. Benign conditions were less radio-opaque and often had ill-defined margins. A diagnostic accuracy of 88% was achieved in differentiating between testicular tumours and benign conditions.
INTRODUCTION Traditionally the diagnosis of scrotal swellings is made by taking a careful history, followed by a meticulous clinical examination, including transillumination of the scrotum. In most cases a confident clinical diagnosis can be made on this alone, but some patients present difficult diagnostic problems. Although a testicular tumour usually presents as a painless swelling of one testicle, the spectrum of clinical presentation is quite wide. In a series of 93 patients with testicular tumours, Irene Cade (1973) reported that pain was a presenting symptom in 21% of seminomas and 35% of teratomas. Fever is occasionally present, and the rapidly growing anaplastic teratoma may give a clinical picture very similar to epididymo-orchitis. About 5-10% of testicular tumours are associated with a secondary hydrocoele (Collins and Pugh, 1964). The technique of soft tissue radiography has been developed in an endeavour to aid the diagnosis of these difficult cases. The primary aim is to differentiate between benign conditions and testicular tumours. TECHNIQUE The technique previously described (Price and Loveday, 1975) has been developed directly from that used for mammography. A single Medichrome film is backed by a fine grain high definition screen, and these are vacuum packed in a thin opaque polyethylene envelope. A GEC Mammostand is used with a Machlett H.D. 50 molybdenum tube, which has a 0.8 mm focal spot. The exposure factors used are 30 kVp, 12-15 mA at 70 cm FFD. The skin radiation dose measured by thermoluminescent dosimetry, is less than 0.25 rad/exposure. The patient is usually positioned in the supine or semi-reclining position on a trolley next to the X-ray machine, with the scrotum resting upon the film in
its vacuum pack. The film holder is removed and the X-ray tube is angled approximately 15~° towards the patient's feet. A certain degree of ingenuity is often required in positioning the patient to overcome variations in build and physique. Oblique views are sometimes appropriate but usually one AP view is adequate. MATERIAL
A total of 85 patients have undergone testicular radiography. The first 10 cases have not been included in the series for assessment of diagnostic accuracy, because of the diagnostic uncertainty associated with a new technique. The diagnoses were consistently wrong until it was realised that malignant tumours were sharply defined. Of the 75 remaining cases, there were 57 benign conditions and 18 testicular tumours. The age range of all patients was from 16 years to 84 years, with an age range of 2 3 46 for testicular tumours. The distribution of the benign conditions is shown in Table 1. The 10 normal patients all presented with scrotal pain, which resolved without specific treatment and the normal X-ray report offered some reassurance to the clinician. Some patients had multiple scrotal pathology. Table 1 -
Benign conditions
Normal Epididymal cysts Chronic infection Hydrocoeles Varicocoeles Torsion Acute abscess TB epididymitis Absent testicle Benign hypertrophy Hydatid of Morgani
10 16 5 9 8 2 1 1 3 1 1
686
CLINICAL RADIOLOGY
The tumours discovered included 11 seminomas, two teratomas and five with mixed teratomas and seminomas. R A D I O L O G I C A L APPEARANCES N o r m a l . - The radiological appearances o f the normal scrotum have been obtained b y studying the 10 normal cases and by observation of the unaffected side of all the other cases. The healthy side o f the scrotum acts as a convenient and accurate control, for it is subject to the same radiographic variables as the pathological side. The normal testes (Fig. 1) are approximately 4 - 5 cm long, are of medium, similar, radio-opacity and both have clearly defined medial borders. The scrotal skin, median septum and fascial planes can be identified and at the upper poles the epididymis and veins m a y be seen.
Fig. 1 - Normal - both testes are the same size and radioopacity. Testicular T u m o u r s . - The appearances of seminomas, teratomas and mixed turnours are similar. There is usually a marked increase in the radioopacity o f the testis compared with the healthy side. The testis is commonly enlarged and its medial margins clearly defined (Fig. 2). The presence o f a secondary hydrocoele produces blurring o f the margins but the density is greater than that seen with a benign hydrocoele.
Fig. 2 - Left mixed tumour - the left testis is more radioopaque than the right and has a well defined margin.
Fig. 3 - Left seminoma - this patient had undescended testes in childhood. An orchidectomy was performed on the right and an ordiopexy on the left. A seminoma developed in this remaining testis.
One of the teratomas in the series showed fine calcification within the tumour (Fig. 4). Professor Diard of the University of Bordeaux has kindly provided us with the scrotal X-rays of two young boys. One with a teratoma, which shows fine calcification within the tumour similar in appearance to our case. The other patient was a 7-year-old b o y with a Leydig cell tumour o f the testes. This shows spectacular lace-like calcification throughout the tumour (Fig. 5).
T a b l e 2 - R a d i o l o g i e a l appearances
Size Density Margin Calcification
Turnouts
Benign conditions
Testis enlarged Very radio-opaque Well defined testicular margin Fine calcification within testes (teratomas and Leydig cell tumours)
Scrotum enlarged Moderately radio-opaque Indistinct testicular margin Coarse plaques of calcification in scrotal wall and epididymis Varicocoeles have a characteristic appearance
SOFT TISSUE RADIOGRAPHY
OF THE TESTES
687
Fig. 4 - Left teratoma - the left testis is enlarged, very radio-opaque and contains some fine calcification. Fig. 6 - Right inflamed epididymal cyst - the right side of the scrotum is enlarged and slightly more radio-opaque than the left. The margins of the testes are indistinct.
Fig. 5 - Leydig cell tumour - marked lace-like calcification Fig. 7 - Left epididymal cyst - the cyst is separate from the Within the tumour. (X-ray kindly supplied by Professor testis. Slight varicocoele is also seen on the left. Francois Diard). Epididymal C y s t s . - Epididymal cysts appear as a generaiised enlargement o f one side o f the scrotum. The radio-opacity is either the same or slightly increased compared with the healthy side. In the larger cysts the margins o f the testes are indistinct and merge with the scrotal wails (Fig. 6). We were unable to explain this finding initially; but at operation it has been found that some low grade inflammation was associated with the cysts in very many of the cases. A few smaller cysts were clearly defined but were separate from the testis (Fig. 7). Epididymal cysts into which there has been haemorrhage m a y be slightly more radio-opaque. V a r i e o c o e l e s . - Radiology was a definite help in the management of one case (Fig. 8). The patient presented with an enlarged and tense scrotum which felt solid and a testicular tumour was considered as a possible diagnosis. Radiologically the testis appeared normal. It was surrounded by numerous serpiginous shadows representing varicose veins o f the pampiniform plexus.
Fig. 8 - Right varicocoele - the normal right testis is surrounded by the serpiginous shadows of the varicocoele. A testicular tumour was suspected clinically. I n f e c t i o n . - It was found that all inflammatory conditions give a similar picture o f a generalised increase in size o f the affected side of the scrotum and a moderate increase in radio-opacity. The most characteristic feature, however, is the blurring of the tissue planes which is seen in acute epididymo-
688
CLINICAL RADIOLOGY
orchitis, acute scrotal abscesses and tuberculous epididymitis (Fig. 9). H y d r o c o e l e s . - The affected side of thb scrotum often shows a marked increase in size and there is an increase in radio-opacity, but with hydrocoeles this is not as marked as with testicular tumours, and the outline of the t~stis cannot be identified (Fig. 113). Torsion o f the t e s t i s . - Radiographs of acute torsion show anatomical distortion of the pedicle with a normal size testis and some blurring oedema. In t h e late stages with chronic torsion or infarction o f the testis, the testis becomes small, dense and fibrotic with a sharply defined margin. C a l c i f i c a t i o n . - Many o f the operative specimens have been X-rayed; but although confirming the site o f calcification this has not provided additional information. Calcification occurs in b o t h benign and malignant disease. Plaques of calcification may commonly occur in the wall of the scrotum. In chronic infective granulomas clusters of fine calcification are demonstrable within the scrotal sac, but are separate from the testes (Fig. 12). A benign type o f calcification has been seen in the b o d y of the epididymis clearly delineating its convoluted duct system. Fine punctate or filigree calcification m a y be seen in teratomas and Leydig cell tumours and this is confirmed on specimen radiography. This type of calcification has not yet been observed in seminomas.
Fig. 1 0 - Right hydrocoele - the hydrocoele is associated with an inguinal hernia. The outline of the right testis cannot be defined.
Fig. 11 - Left epididymal calcification. Some calcification is also seen in the wall of the right SCrOtum. The testes are normal.
DIAGNOSTIC ACCURACY Although in some cases it was possible to make a definitive diagnosis, the objective has been to distinguish between testicular tumours and benign conditions, and an assessment of diagnostic accuracy has been made on these factors (Table 3). Of the 75 cases in the series, a correct diagnosis was made in 66 patients when compared with the patient's final clinical or histological diagnosis. Fig. 12 - Left chronic granuloma - the calcification is in the granuloma. The testes are normal, but a testicular tumour was suspected clinically. Table 3 - Diagnostic accuracy
Benign condition o f testicular tumours
Fig. 9 - Right tuberculous epididymitis - the typical blurred outline of infection is shown. The calcification was found to be in the right epididymis and the left scrotal wall.
Total in series Correct diagnosis for benign and malignant False negative (malignant tumours) False positive Percentage accuracy for benign and malignant disease
75 66 2 7 88
SOFT TISSUE
RADIOGRAPHY
There were seven false positive and two false negative reports for tumour diagnosis. This gives an overall diagnostic accuracy o f 88% for b o t h benign and malignant disease. Four o f the false positive cases came to operation; three showed chronic infective granulomas and one was normal. The other three were not operated upon, but settled after conservative treatment. The radiological diagnosis in these cases was equivocal and caution was expressed with such terms as, 'the presence o f a testicular turnout cannot be entirely excluded'. One false negative case was given an inconclusive report, and in retrospect this would probably be reported as a tumour, with our present experience. The other false negative case was disappointing as a confident diagnosis of normality was made, and in retrospect the radiological appearances are still normal. Fortunately the clinical features were sufficiently suspicious to warrant operation and a small seminoma was found.
OF THE TESTES
689
screens with Medichrome films enables the radiation dose to the gonads to be kept to a very low level, certainly under 0.25 rad per exposure. Analysis of our figures shows that the radiological features are being established with some degree of consistency. The clinicians who have referred the cases feel that soft tissue radiography o f the testes forms an extension o f the clinical examination, and when allied with the full clinical picture is a useful aid to diagnosis and management. It is suggested that these early results justify continued development and assessment o f the technique. Acknowledgements. - We are grateful to Mr T. P. N. Jenkins, FRCS, who originally suggested the approach. Also to Mr P. D. Butler for his technical skills in producing the films. Our thanks to Professor Diard for allowing us to use two of his cases and for his encouragement. REFERENCES
DISCUSSION Soft tissue radiography of the testes has not been attempted before. The introduction o f low kVp apparatus and suitable film for mammography now enables satisfactory soft tissue radiography o f the testes to be obtained. The use of high definition
50
Cade, Irene (1973). The clinical picture and management of testicular tumours. ClinicalRadiology, 24, 385-391. Collins, D. H. & Pugh, R. C. B. (1974). The pathology of testieular tumours. British Journal of Urology, 36 Suppl. to volume 36. Price, J. L. & Loveday, B. J. L. (1975). Preliminary communication. Soft tissue radiography of the testicles. British Journal of Radiology, 48, 179-180.