Segmental testicular infarction: role of imaging

Transcription

1 Segmental testicular infarction: role of imaging Poster No.: C-0583 Congress: ECR 2013 Type: Scientific Exhibit Authors: F. Albarello, S. Zago, P. Campioni, M. Giganti, G. Parenti ; Ferrara/IT, Ravenna/IT Keywords: Ischemia / Infarction, Contrast agent-intravenous, UltrasoundColour Doppler, Ultrasound, MR, Genital / Reproductive system male, Acute DOI: /ecr2013/C-0583 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 28

2 Purpose Segmental testicular infarction (STI) is a rare ischaemic process with a generally idiopathic aetiology. The most frequently reported presentation is acute scrotum, a nonspecific clinical setting in which imaging has a primary role in the differential diagnosis [1, 2]. The literature describes several radiological findings that can help the radiologist differentiate an STI from a hypovascular testicular tumour, thus making possible a conservative therapeutic approach [1, 3-7]. We report our experience through a description of the most significant radiological findings observed in STI, evaluated with colour Doppler ultrasound (CDUS), contrast-enhanced ultrasound (CEUS) and magnetic resonance imaging (MRI) at onset and during follow-up in order to establish a correct clinical-therapeutical management. Images for this section: Page 2 of 28

3 Fig. 1: Segmental testicular infarction of the upper pole at presentation. a.cdus, longitudinal view: oval inhomogeneous hypoechoic avascular lesion with ill-defined borders. b.sagittal T1-weighted MRI: inhomogeneous high-signal-intensity lesion. c.sagittal T2-weighted MRI: inhomogeneous low-signal-intensity lesion. d.sagittal gadolinium-enhanced T1-weighted MRI: perilesional rim enhancement. Page 3 of 28

4 Methods and Materials In a retrospective cross sectional study the suspected STI found with colour Doppler ultrasonography (CDUS) was assessed in a group of 16 men with magnetic resonance imaging (MRI). Furthermore, 6 men underwent contrast enhancement ultrasonography (CEUS) at onset and during follow-up in order to analyse lesion contrast enhancement patterns and gather their progression. Patient selection The study population was selected from a database of 800 patients referred to our US division over a 8-year period (January 2004 to November 2012) for urgent or priority testicular examination for suspected acute or subacute scrotal disease. The criteria adopted for establishing a diagnosis of STI, as previously described [8], were: at US, the presence of hypoisoechoic intratesticular echostructural changes, with no microcalcification, no mass effect, and no or markedly reduced CDUS signal, in the absence of signs of infiltration of parenchymal vessels, capsule and scrotal tunics; at MRI, the presence of abnormal intratesticular signal with no contrast enhancement; at CDUS and MRI follow-up, the absence of progression and/or presence of a reduction in size due to lesion involution, with absent or reduced flow; negative tumour markers for primary malignant testicular disease (alpha fetoprotein, lactate dehydrogenase, human beta chorionic gonadotropin); no history of testicular trauma and no clear sign of acute inflammation, with the exception of two cases of subacute epididymitis. Imaging techniques All patients underwent CDUS performed by experienced operators who used a highresolution transducer (7-17 MHz linear-array probe) with B-flow (B-mode flow), colour Doppler and power Doppler (GE Healthcare Logic 7, Philips iu22). Automatic settings for testicular examination were used, and the operator modified the pulse repetition frequency (PRF), focal zone, gain and wall filter to obtain optimal colour Doppler flow. CEUS was performed using sulphur hexafluoride microbubbles (SonoVue, Bracco), with the injection of a 2 cc to 2.5 cc bolus followed by 10 cc of saline solution. In the presence of abnormalities of the testicular parenchyma suggestive of STI, an MRI was performed to confirm or clarify CDUS findings. A Philips Achieva 1.5 Tesla system was used with a 14 cm circular surface coil, cm field of view, matrix and 3 mm slice thickness. Images were acquired in the three orthogonal planes with T2weighted fast spin-echo (FSE) sequences and in the axial plane with T2-weighted spoiled Page 4 of 28

5 gradient echo (GRE) sequences to detect haemoglobin breakdown products at the site of haemorrhagic infarction. After intravenous injection of gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA), T1-weighted images in the axial and coronal planes were acquired. All patients were examined in the supine position with a towel between their legs to reduce testicular motion artefacts. The examination took approximately min. Image and data analysis US and MRI were assessed for size, morphology, echogenicity, signal intensity, presence/absence of vascularity and pattern of contrast enhancement of the lesions in their various phases of progression. We also gathered information about patient age, clinical presentation and possible causes of testicular infarction. Results CDUS revealed hypoechoic areas associated with an absent testicular blood flow in 16 of the 800 patients examined (1.75% of the total). Age range of these 16 patients was years. Clinical presentation in 9 of these 16 patients was acute scrotum: 8 with testicular tenderness after a prior acute episode and 1 with testicular pain 25 days after varicocele embolisation. No patient reported episodes of trauma prior to hospital admission. At presentation, all patients underwent CDUS of the affected testis, which brought to light the following characteristics: the common feature among all 16 patients was single or multiple hypoechoic areas with no sign of microcalcifications, poor vascularity and no mass effect and/or signs of infiltration of vascular structures or scrotal tunics; in 10 of the 16 patients (62,5%), presence of a single hypoechoic lesion within the testis: four of these lesions were oval or rounded in shape, whereas the other 6 were situated peripherally and had a prevalently wedge-shaped appearance with the base towards the scrotal tunics and the apex at the centre of the testicle; in 4 of these 10 patients, the lesions had ill-defined margins; echostructural abnormalities were located in the upper testicular pole in 3 of these 10 patients (Fig. 1a), in the middle third in 3 patients and in the lower pole in 4 patients; Page 5 of 28

6 Fig. 1: Segmental testicular infarction of the upper pole at presentation. a.cdus, longitudinal view: oval inhomogeneous hypoechoic avascular lesion with ill-defined borders. b.sagittal T1-weighted MRI: inhomogeneous high-signal-intensity lesion. c.sagittal T2-weighted MRI: inhomogeneous low-signal-intensity lesion. d.sagittal gadolinium-enhanced T1-weighted MRI: perilesional rim enhancement. References: Radiology, University of Ferrara, S.Anna - Ferrara/IT in 6 of the 16 patients (37,5%) multiple hypoechoic areas in the testicular parenchyma were visualised, which appeared avascular, with no capsule but with a thin pseudocapsule and ill-defined margins; these findings were defined as plurisegmental infarction, i.e. the expression of ischaemia in different phases of evolution or different ischaemic settings (Fig. 2a); Page 6 of 28

7 Page 7 of 28

8 Fig. 2: Multiple ischaemic lobules in the left testis: early findings. ùa.cdus image, longitudinal view: multiple inhomogeneously hypoechoic, avascular areas. c.axial T2-weighted MRI: multiple low-signal-intensity areas. References: Radiology, University of Ferrara, S.Anna - Ferrara/IT only in 2 cases were testicular abnormalities associated with subacute testicular inflammation. Within 1-5 days of CDUS study, all patients were examined with MRI (Figs. 1b-d, 2c and 3), which confirmed the presence of focal lesions with low signal intensity in the T1 and T2-weighted sequences without contrast enhancement in 14 of 16 patients (87,5%). Page 8 of 28

9 Page 9 of 28

10 Fig. 3: Multiple ischaemic lobules in the left testis: early findings. b.axial T1-weighted MRI: multiple areas with high and intermediate signal intensity. d.sagittal gadoliniumenhanced T1-weighted MRI: multiple wedge-shaped areas with low signal intensity and perilesional rim enhancement. References: Radiology, University of Ferrara, S.Anna - Ferrara/IT Morphology was oval, rounded or wedge shaped. In GRE sequences, areas of low signal intensity were seen, indicating the presence of haemoglobin breakdown products. These were most evident in lesions displaying hyperintense signal intensity in the T1-weighted sequence and were most likely the result of extravasation of blood in the setting of the infarction. All 16 patients were subsequently followed up with CDUS and MRI in a timeframe ranging from 20 to 200 days (Figs. 4-8). CDUS follow-up showed progressive reduction in size of intratesticular lesions, which prevalently appeared inhomogeneously hypoechoic, as well as a higher definition of the lesions themselves with respect to the surrounding parenchyma. At days from the acute event, follow-up performed with MRI showed lesions with little change or a slight reduction in size and better-defined margins. Page 10 of 28

11 Fig. 4: Segmental testicular infarction in the upper pole examined 60 days after onset of acute testicular pain. a.cdus image, longitudinal view: reduction in lesion size. b.ceus image, longitudinal view: avascular lesion. c.coronal T1-weighted MRI: lowsignal-intensity lesion. d.coronal T2-weighted MRI: low- signal-intensity lesion. References: Radiology, University of Ferrara, S.Anna - Ferrara/IT Page 11 of 28

12 Fig. 5: Multiple ischaemic lobules in the left testis examined 20 days after onset of acute left testicular pain. a.cdus image, longitudinal view: hypoechoic avascular areas with reduction in size. b.axial T1-weighted MRI: high-signal-intensity lesions with hypoechoic peripheral rim. c.axial T2-weighted MRI: high-signal-intensity lesions with hypoechoic peripheral rim. d.axial gadolinium-enhanced T1-weighted MRI. References: Radiology, University of Ferrara, S.Anna - Ferrara/IT At days, lesions appeared smaller in size and prevalently hypoisointense in T1and T2-weighted images. In seven cases, there was a retraction of the tunica albuginea, which also appeared thickened, associated with distortion and thickening of the lobular septa. There were no signs of intralesional or perilesional enhancement (Figs. 4-8). Page 12 of 28

13 Fig. 6: Multiple ischaemic lobules in the left testis examined 100 days after onset of acute left testicular pain. a.cdus image, longitudinal view: hypoechoic avascular areas with reduction in size. b.cdus image, axial view: hypoechoic avascular areas with reduction in size. c.axial T1-weighted MRI: low-signal-intensity lesions; retraction of the tunica albuginea. d.axial T2-weighted MRI: low-signal- intensity lesions; retraction of the tunica albuginea. References: Radiology, University of Ferrara, S.Anna - Ferrara/IT We performed CEUS (SonoVue) in 6 patients (37,5%) at presentation and at days. The study showed and confirmed abnormalities detected with CDUS and MRI, which appeared prevalently avascular in all study phases. The technique also proved useful in monitoring STI in that it showed the progressive reduction in size of ischaemic lesions. Following detailed evaluation of CDUS and MRI features at presentation and especially during follow-up, 2 patients underwent orchiectomy, with a histological diagnosis of B-cell Page 13 of 28

14 lymphoma and a hemorrhagic STI. In these cases, CDUS at presentation showed the coexistence of multiple hypoechoic oval-shaped lesions with no mass effect and mildly vascular appearance, which had been initially interpreted as STI. At presentation, the only MRI finding divergent from the typical STI pattern was a homogeneous uptake of Gd by several parenchymal lesions. MRI follow-up performed at 20 and 30 days proved crucial in confirming the presence of multiple areas characterised by hypointense signal with a peripheral hyperintense halo in T1-weighted and hypointense signal in T2-weighted sequences. At the same time, the two MRI examinations revealed stable lesion size and the almost constant and homogeneous contrast enhancement in the first patient and a low reduction of the mass in the other one (Fig. 9-10). Fig. 9: Testicular B-cell lymphoma. a.cdus image, longitudinal view: multiple oval hypoechoic hypovascular areas without mass effect. b.cdus image, axial view: oval hypoechoic, hypovascular area without mass effect. c.sagittal T1-weighted MRI: low-signal-intensity area with high-signal rim. d.sagittal T2-weighted MRI: multiple inhomogeneous low-signal-intensity areas References: Radiology, University of Ferrara, S.Anna - Ferrara/IT Images for this section: Page 14 of 28

15 Fig. 1: Segmental testicular infarction of the upper pole at presentation. a.cdus, longitudinal view: oval inhomogeneous hypoechoic avascular lesion with ill-defined borders. b.sagittal T1-weighted MRI: inhomogeneous high-signal-intensity lesion. c.sagittal T2-weighted MRI: inhomogeneous low-signal-intensity lesion. d.sagittal gadolinium-enhanced T1-weighted MRI: perilesional rim enhancement. Page 15 of 28

16 Page 16 of 28

17 Fig. 2: Multiple ischaemic lobules in the left testis: early findings. ùa.cdus image, longitudinal view: multiple inhomogeneously hypoechoic, avascular areas. c.axial T2weighted MRI: multiple low-signal-intensity areas. Page 17 of 28

18 Page 18 of 28

19 Fig. 3: Multiple ischaemic lobules in the left testis: early findings. b.axial T1-weighted MRI: multiple areas with high and intermediate signal intensity. d.sagittal gadoliniumenhanced T1-weighted MRI: multiple wedge-shaped areas with low signal intensity and perilesional rim enhancement. Fig. 4: Segmental testicular infarction in the upper pole examined 60 days after onset of acute testicular pain. a.cdus image, longitudinal view: reduction in lesion size. b.ceus image, longitudinal view: avascular lesion. c.coronal T1-weighted MRI: lowsignal-intensity lesion. d.coronal T2-weighted MRI: low- signal-intensity lesion. Page 19 of 28

20 Fig. 5: Multiple ischaemic lobules in the left testis examined 20 days after onset of acute left testicular pain. a.cdus image, longitudinal view: hypoechoic avascular areas with reduction in size. b.axial T1-weighted MRI: high-signal-intensity lesions with hypoechoic peripheral rim. c.axial T2-weighted MRI: high-signal-intensity lesions with hypoechoic peripheral rim. d.axial gadolinium-enhanced T1-weighted MRI. Page 20 of 28

21 Fig. 6: Multiple ischaemic lobules in the left testis examined 100 days after onset of acute left testicular pain. a.cdus image, longitudinal view: hypoechoic avascular areas with reduction in size. b.cdus image, axial view: hypoechoic avascular areas with reduction in size. c.axial T1-weighted MRI: low-signal-intensity lesions; retraction of the tunica albuginea. d.axial T2-weighted MRI: low-signal- intensity lesions; retraction of the tunica albuginea. Page 21 of 28

22 Page 22 of 28

23 Fig. 7: Multiple ischaemic lobules in the left testis examined 200 days after onset of acute left testicular pain. a.cdus image, longitudinal view: hypoechoic avascular areas with reduction in size. c.sagittal T2-weighted MRI: low-signal-intensity lesions with slight retraction of the tunica albuginea. Page 23 of 28

24 Page 24 of 28

25 Fig. 8: Multiple ischaemic lobules in the left testis examined 200 days after onset of acute left testicular pain. b.sagittal T1-weighted MRI: low-signal- intensity lesions. d.sagittal gadolinium-enhanced T1-weighted MRI. Fig. 9: Testicular B-cell lymphoma. a.cdus image, longitudinal view: multiple oval hypoechoic hypovascular areas without mass effect. b.cdus image, axial view: oval hypoechoic, hypovascular area without mass effect. c.sagittal T1-weighted MRI: low-signal-intensity area with high-signal rim. d.sagittal T2-weighted MRI: multiple inhomogeneous low-signal-intensity areas Page 25 of 28

26 Fig. 10: Testicular B-cell lymphoma. e.sagittal gadolinium-enhanced T1-weighted MRI: homogene- ous contrast enhancement in the lesion and rim contrast enhancement. Page 26 of 28

27 Conclusion Our study reconfirms the indispensable role of imaging (CDUS, MRI, CEUS) in characterising parenchymal abnormalities that are doubtful or suspicious for STI. The nature of the lesions can also be confirmed and monitored during follow-up, and CEUS may be considered a valid supplement to CDUS and MRI in this context for a correct clinical-therapeutical management allowing a conservative treatment in the majority of the patients we observed. References Pavlica P, Barozzi L (2001) Imaging of the acute scrotum. Eur Radiol 11: Gianfrilli D, Isidori AM, Lenzi A (2008) Segmental testicular ischaemia: presentation, management and follow-up. Int J Androl 32: Ferna#ndez-Pe#rez GC, Tarda#guila FM, Velasco M et al (2005) Radiologic findings of segmental testicular infarction. AJR Am J Roentgenol 184: Bilagi P, Sriprasad S, Clarke JL et al (2007) Clinical and ultrasound features of segmental testicular infarction: Six-year experience from a single centre. Eur Radiol 17: Kodama K, Yotsuyanagi S, Fuse H et al (2000) Magnetic resonance imaging to diagnose segmental testicular infarction. J Urol 163: Watanabe Y, Dohke M, Ohkubo K et al (2000) Scrotal disorders: evaluation of testicular enhancement patterns at dynamic contrast-enhanced subtraction MR imaging. Radiology 217: Kim HK, Goske MJ, Bove KE, Minovich E (2009) Segmental testicular infarction in a young man simulating a testicular tumor. Pediatr Radiol 39: G.C. Parenti, M. Sartoni, E. Gaddoni, S. Zago, P. Campioni, P. Mannella (2012) Imaging of segmental testicular infarction: our experience and literature review. Radiol med 117: Personal Information Fabrizio Albarello MD, Department of Radiology, S.Anna Hospital, University of Ferrara, Ferrara, Italy; fabrizioalbarello@yahoo.it Page 27 of 28

28 Silvia Zago MD, Department of Pathological Anatomy, OC S.Maria delle Croci, Ravenna, Italy; Paolo Campioni MD, Department of Radiology, S.Anna Hospital, University of Ferrara, Ferrara, Italy; Melchiore Giganti MD, Department of Radiology, S.Anna Hospital, University of Ferrara, Ferrara, Italy; Gian Carlo Parenti MD, Department of Radiology, OC S.Maria delle Croci, Ravenna, Italy; Page 28 of 28