Testis Elastography. Paul S. Sidhu. Professor of Imaging Sciences. King s College Hospital London

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1 Testis Elastography Paul S. Sidhu Professor of Imaging Sciences King s College Hospital London

2 Testicular Elastography Strain elastography Point Shear wave elastography 2D Shear wave elastography Multiparametric Ultrasound (MPUS) imaging Bamber J, Cosgrove D, Dietrich CF, Fromageau J, Bojunga J, Calliada F, et al. EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: Basic principles and technology. Ultraschall Med. 2013;34(2):

3 Testicular Elastography Elastography Direct measure of the stiffness of a lesion Malignant lesions are harder than benign lesions Adjunct to conventional US EFSUMB GUIDELINES ELASTOGRAPHY NON-LIVER APPLICATIONS 2018 GET-TOGETHER MEETING IN FRANKFURT ON 17 TH FEBRUARY STEERING COMMITTEE ADRIAN SĂFTOIU ODD HELGE GILJA PAUL SIDHU CHRISTOPH F. DIETRICH VITO CANTISANI

4 Testicular Elastography Elastography Direct measure of the stiffness of a lesion Malignant lesions are harder than benign lesions Adjunct to conventional US EFSUMB GUIDELINES ELASTOGRAPHY NON-LIVER APPLICATIONS 2018 Clinical applications The use of all forms of elastography in the assessment of focal testicular lesions is promising, with tissue hardness confirmed with both SE and SWE techniques, but with overlap in findings between benign and malignant neoplasms. The current status would allow elastography to be an adjunct to the overall ultrasonographic examination rather than a standalone technique. GET-TOGETHER MEETING IN FRANKFURT ON 17 TH FEBRUARY STEERING COMMITTEE ADRIAN SĂFTOIU Limitations and artifacts The values obtained for SWE vary between different machines and are not interchangeable. The problems associated with the areas of fibrosis adjacent to the tunica albuginea hamper assessment of focal lesions adjacent to this region. Measurements using SWE between the center and peripheral zones differ and the point of measurement requires standardization. ODD HELGE GILJA PAUL SIDHU CHRISTOPH F. DIETRICH VITO CANTISANI Recommendation The application of strain or shear wave elastography techniques in the evaluation of focal testicular lesions are recommended only in conjunction with other ultrasound techniques, as there is overlap in values from benign and malignant neoplasms. (Level of Evidence;3A Grade of Evidence; B)

5 Testicular Elastography Strain Elastography of Normal Testis The blue rim on the outside of the normal testis is referred to as a boundary effect. It is thought to arise because the soft tissue is more tethered at the testicular margin and so suffers less deformation when stress is applied. This is demonstrated in an exaggerated fashion in a long standing atrophied testis. Normal Missed Torsion Infertility Atrophy

6 Testicular Elastography Normal Strain Elastography of Normal Testis The blue rim on the outside of the normal testis is referred to as a boundary effect. It is thought to arise because the soft tissue is more tethered at the testicular margin and so suffers less deformation when stress is applied. This is demonstrated in an exaggerated fashion in a long standing atrophied testis. Germ Cell Tumour Focal lesion in the testis that of a seminoma, with blue indicating hardness and strain ratio of 43.72

7 Strain Elastography

8 Testicular Elastography Light vertical manual compression until optimised 256 colour scale (Red = Soft, Blue = Hard) Manually drawn ROI within the lesion and normal tissue Scoring system created (1-6)

9 Testicular Elastography

10 Testicular Elastography Study Lesions (n) Comparison VES VES SR SR (Reference) Sensitivity Specificity Sensitivity Sensitivity 100% 81% N/A N/A Aigner, 2012 (10) 50 Neoplasms Vs nonneoplasms Goddi, 2012 (9) 144 Malignant Vs Benign 87.5% 98.2% N/A N/A lesions Marsaud, 2015 (19) 34 Malignant Vs Benign 96.2% 37.5% N/A N/A lesions 98% 25% 90% 45% Schroder, 2016 (20) 68 Neoplasms Vs nonneoplasms Pozza, 2016 (18) 106 Malignant Vs Benign 81.1% 79.7% 59.4% 66.6% lesions 58.7% 100% 69.3% 61.3% Neoplasms Vs Nonneoplasms Auer, 2017 (16) 55 Malignant Vs Benign 100% 72.1% N/A N/A lesions

11 Testicular Elastography

12 Testicular Elastography

13 Testicular Elastography Extra-testicular Lesion Adenomatoid Lesion

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15 Testicular Elastography

16 Testicular Elastography Colour coded shear wave elastography

17 Testicular Elastography EFSUMB GUIDELINES ELASTOGRAPHY NON- LIVER APPLICATIONS 2018 GET-TOGETHER MEETING IN FRANKFURT ON 17 TH FEBRUARY STEERING COMMITTEE ADRIAN SĂFTOIU ODD HELGE GILJA PAUL SIDHU CHRISTOPH F. DIETRICH VITO CANTISANI Strain elastography 1.Strain elastography has been the most employed technique in assessing testicular lesions. 2. Although early studies have commented on the possibility of differentiating malignant from benign lesions with certainty using SE and a strain ratio (SR) these findings have not been confirmed in recent studies. 3. A number of case series detailing the use of SE and SR (some in combination with CEUS) have described the findings in Leydig cell tumours, epidermoid cysts, haematoma, lymphoma, focal infarction, capillary haemangioma, adrenal rest cells and in extra-testicular lesions, without comparison between the findings of these different lesions. Shear wave elastography 1. There is limited information regarding the use of shear wave elastography in the evaluation of testicular lesions. 2. SWE in the overall assessment of background parenchyma have suggested values may be raised with testicular microlithiasis, infertility, undescended testis, and has the potential to differentiate seminomas from non-seminomatous lesions and has been evaluated in burnt-out tumours. 3. No prospective study reporting the differences in SWE in focal testicular lesions has been published. Recommendation The application of strain or shear wave elastography techniques in the evaluation of focal testicular lesions are recommended only in conjunction with other ultrasound techniques, as there is overlap in values from benign and malignant neoplasms. (Level of Evidence;3A Grade of Evidence; B)

18 Multiparametric Ultrasound (MP-US) The addition of contrast-enhanced ultrasound (CEUS) and strain elastography (SE) to the established B-mode and colour Doppler US, facilitates testicular multiparametric ultrasound (MP-US) to be performed, providing additional information: CEUS: dynamic functional imaging, including demonstration of presence or absence of vascularity SE: a measure of tissue stiffness Classic seminoma: CEUS and SE appearances Huang DY, Sidhu PS. Focal testicular lesions: color Doppler ultrasound, contrast-enhanced ultrasound and tissue elastography as adjuvants to the diagnosis. Br J Radiol. 2012;85 Spec No 1:S Konstantatou E, Huang DY, Derchi LE, Bertolotto M, Valentino M, Sidhu PS. Focal testicular lesions: Use of contrastenhanced ultrasound (CEUS) and real-time Tissue Elastography (RTE) as adjuvant Sonographic techniques in determining clinical management. RSNA 2014 De Zordo T, Stronegger D, Pallwein-Prettner L, Harvey CJ, Pinggera G, Jaschke W, et al. Multiparametric ultrasonography of the testicles. Nature reviews Urology

19 MPUS of Scrotal Diseases

20 MPUS - Haematoma

21 Testicular Indeterminate Tumours: Can CEUS and Elastography Help? Leydig Cell Tumour Heterogenous Highly vascular on CDUS Rapid and longer lasting enhancement on CEUS Strain ratio 1.56 Seminoma More homogenous Less vascular on CDUS Rapid and shorter lasting enhancement on CEUS Strain ratio 43.72

22 CEUS: Where CEUS is useful? The presence or absence of vascularity can be visualized with CEUS CEUS can conclusively demonstrate of lack of vascularity The absence of vascularity is an important indicator of benign disease. MP-US of an epidermoid cyst: CEUS demonstrates conclusively there is no internal vascular enhancement. Patel K, Sellars ME, Clarke JL, Sidhu PS. Features of testicular epidermoid cysts on contrast-enhanced sonography and real-time tissue elastography. J Ultrasound Med. 2012;31(1): Huang DY, Sidhu PS. Focal testicular lesions: color Doppler ultrasound, contrast-enhanced ultrasound and tissue elastography as adjuvants to the diagnosis. Br J Radiol. 2012;85 Spec No 1:S41-53.

23 Where CEUS is useful? The pattern of vascularity can be visualised with CEUS. Marked hyper-vascularization is frequently observed in Leydig cell tumors CEUS improves identification Leydig cell tumors by this features for TSS consideration. Split screen images of CEUS and grey - scale US Huang DY, Eckersley RJ, Sellars ME, Sidhu PS. Differentiation Between Benign Leydig Cell and Malignant Germ Cell Testicular Tumors with Qualitative and Quantitative Contrast - Enhanced Ultrasound Assessments. European Congress of Radiology. 2013; Scientific presentation Lock G, Schroder C, Schmidt C, Anheuser P, Loening T, Dieckmann KP. Contrast-Enhanced Ultrasound and Real-Time Elastography for the Diagnosis of Benign Leydig Cell Tumors of the Testis - A Single Center Report on 13 Cases. Ultraschall Med. 2014

24 Indeterminate lesion - Pre-operative assessment (a) (b)

25 Indeterminate lesion - Pre-operative assessment

26 Indeterminate lesion - Intraoperative localisation

27 MPUS of Scrotal Diseases Seminoma

28 MPUS of Scrotal Diseases Epidermoid Cyst

29 MPUS of Scrotal Diseases Embryonal Cell Carcinoma

30 MPUS of Scrotal Diseases Haematoma

31 Segmental Infarction MPUS of Scrotal Diseases

32 Testicular Indeterminate Tumours: Can CEUS and Elastography Help?

33 Testicular Indeterminate Tumours: Can CEUS and Elastography Help?

34 Testicular Indeterminate Tumours: Can CEUS and Elastography Help?

35 Thank you