scrotal masses

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Scrotal Masses1

TestisEpididymisSpermatic cordTheir fascial coveringsContents of ScrotumStructure of Testis

Structure of Testis

Imaging The first imaging procedure to evaluate the scrotum.The study has to be performed with high frequency transducers (>10 MHz) with color Doppler facilities.Ultrasonography

Ultrasonography

MRI can be useful in the evaluation of scrotal masses as a problem-solving technique:Discrepancies between US and clinical findings.Diffuse, non-specific testicular involvement seen on US scanning.Fibrous lesions, lipomas or hemorrhage are suspected.Magnetic Resonance Imaging (MRI)

Testis.Tunica albuginea.The mediastinum testis.The epididymis.Magnetic Resonance Imaging (MRI)

Most solid lesions originating from the testes are malignant, while most lesions originating from extratesticular structures are benignThe most common extratesticular neoplasms are benign lipomas, usually originating from the spermatic cord, and adenomatoid tumors, most often from the epididymis.General Principles for Scrotal MassesIn patients with a scrotal mass, imaging is requested to answer the following five questions:Is there a definite mass?Is the mass intra- or extratesticular?Is the mass bilateral?Is the mass cystic or solid?Is the nature of the lesion identifiable?General Principles for Scrotal MassesIs there a definite mass?US is almost 100% sensitive in the identification of presence of scrotal masses.Diagnostic difficulties leading to false-negative results are rarely encountered, and are mostly due to:Presence of isoechogenic intratesticular lesionsDiffuse testicular involvement, especially in children with yolk-sac tumorsExtratesticular lipomas can be difficult to identify, being often isoechoic to surrounding subcutaneous tissue.General Principles for Scrotal MassesGeneral Principles for Scrotal MassesIs the mass intra- or extratesticular?Differentiation can be made by US in almost all cases.Palpation during US examination can help to localize the mass.General Principles for Scrotal MassesIs the mass bilateral?Testicular tumors can be bilateral (38% of lymphomas, 2% of seminomas).General Principles for Scrotal MassesIs the lesion cystic or solid?US can easily differentiate a solid from a cystic lesion.A lesion may be defined as a cyst only if it is completely anechoic, with increased through transmission and presence of thin walls, without any vegetations or irregularities.General Principles for Scrotal MassesIs the nature of the lesion identifiable?Identification of the nature of scrotal masses cannot be based on imaging methods alone.Localization of the mass is important in predicting the nature of the lesion.Most extratesticular lesions are benignMost intratesticular masses are malignant.The structural pattern of the mass is the second important factor to consider.Most cystic lesions are benign, while solid nodules are more often malignant.17Testicular TumorsAge:First Decade Yolk Sac Tumors Teratomas.Second & Third Decade Teratoma & Choriocarcinoma.Forth And Fifth Decade Seminoma.

Testicular TumorsTumors Markers:Alpha Fetoprotein All Yolk Sac Tumors 75% Of Embryonal Carcinoma.Human Chorionic Gonadotrophin (hCG) All Choriocarcinoma - 60% Embryonal Carcinoma.19

Typical Appearance of Scrotal MassesEpididymal CystA common benign lesion (retention cyst).It is a cyst filled with cheesy laminated material that appears solid on imaging.Typical Appearance of Scrotal Masses

Epidermoid CystA rare benign tumor (approximately 1% of all testicular tumors).It is a cyst filled with cheesy laminated material that appears solid on imaging.Typical Appearance of Scrotal Masses

Epidermoid CystAt US, the lesion is seen as rounded or oval shaped nodule with regular outer margins.The lesion tends to be hyperechoic, sometimes calcific outer wall is seen, and an internal onion ring structure is characteristic of an epidermoid cyst. No vascular signals are seen at Doppler evaluationTypical Appearance of Scrotal Masses

Epidermoid CystAt MRI, a laminated appearance, with alternate low-and high-signal intensity areas can be detected on T2-weighted images.Typical Appearance of Scrotal Masses

Seminoma US: Seminomas are well defined and homogeneously hypoechoicTypical Appearance of Scrotal Masses

Seminoma On MRI, Homogeneously hypointense on T2-weighted images. Larger tumors may be more heterogeneousTypical Appearance of Scrotal Masses

Non-Seminomas Non-seminomatous lesions are more heterogenous with areas of hemorrhage and calcification. The tunica albuginea may be invaded.Typical Appearance of Scrotal MassesNon-Seminomas Typical Appearance of Scrotal Masses

Non-Seminomas Typical Appearance of Scrotal Masses

Lymphoma US findings are usually sufficient to suggest the diagnosis. The testis is typically replaced by infiltrative hypoechoic hypervascular lymphoid tissue.Typical Appearance of Scrotal Masses

Lymphoma MR imaging findings are similar, with the testis being replaced by tissue that is low signal intensity on T1- and T2-weighted images, with low-level enhancement (less than the normal testis)Typical Appearance of Scrotal Masses

Burned-out" Germ Cell TumorExtra-Testicular pseudo-tumorsTesticular pseudo-tumors32Thank You