Value Of High Frequency Ultrasonography In The Diagnosis Of Testicular Tumors

Objective To explore the value of high frequency ultrasonography in the diagnosis of testicular tumors.The clinical data of 315 cases of different types of testicular tumors and high frequency ultrsonographic appearances were retrospectively analyzed,so as to add the sonographer recognition of different types of testicular tumors and improve the preoperative diagnosis coincidence rate of different types of testicular neoplasms.Methods 315 cases of testicular tumors were confirmed by the surgery or biopsy and pathologic in Shandong Provincial Hospital from January 1,2000 to October 1,2017.This group of 13 types of testicular tumors,according to the numbers of cases from more to less in turn was:seminoma 98 cases(31.1%),teratoma 74 cases(23.5%),testicular epidermoid cyst 36 cases(11.5%)yolk sac tumor 23 cases(7.3%);lymphoma 22 cases(7.0%);embryonal carcinoma 21 cases(6.7%);mixed germ cell tumor 16 cases(5.1%),Leydig cell tumor 12 cases(3.8%),leukemic infiltration to the testis 6 cases(1.9%),Sertoli cell tumor 3 cases(0.9%),metastases to the testis 2 cases(0.6%),choriocarcinoma 1 case(0.3%),and testicular adrenal rest 1 case(0.3%).Tumor tissue occupied the entire testicular parenchyma of the affected side,which was called a diffused tumor,and the tumor tissue replaced part of the normal testis,which was called a focal tumor.The medical history of cryptorchidism,patient age,tumor size,number,shape,echotexture,diffused or focal lesion,with or without cystic change and calcification in the tumor tissue,condition of microlithiasis and metastases,peak systolic velocity,and resistive index were recorded respectively.The involved conditions of tunica albuginea,epididymis,and spermatic cord,with or without inguinal and retroperitoneal lymphadenopathy were observed and recorded preoperative.The levels of serum alpha fetoprotein and ? subunit human chorionic gonadotropin were determined preoperatively.SPSS Statistics 24.0(IBM,US)was used for statistical analysis.Quantitative data was presented as mean± standard deviation(x±s).The test of homogeneity of variance was performed in each group,and one-way ANOVA was used to compare the differences between groups.The LSD-t test was used for the multiple comparisons between groups when the homogeneity of variance was assumed;otherwise Tamhane's test was applied.Qualitative data was presented as rate and/or proportion.Comparison between groups was performed using the chi square test,Scheffe test was used for the multiple comparisons between groups.P<0.05 was considered to be statistically significant.Results There were 55 cases of diffused seminomas,including 18 cases of multiple nodular fusion type,4 cases of homogeneous echogenicity type,27 cases of inhomogeneous echogenicity(map like)type,and 6 cases of cystic-solid mixed echogenicity type.There had 43 cases of focal seminomas,including 10 cases of multiple nodular close to each other type,10 cases of homogeneous echogenicity type,22 cases of inhomogeneous echogenicity type,and 1 case of cystic-solid mixed echogenicity type.There were 13 cases of diffused teratomas,including 12 cases of cystic changes(8 cases with calcification)and 1 case of solid mixed echogenicity.61 cases belonged to focal teratomas,of which had totally calcified 1 case,totally cystic change 1 case,solid heterogeneous echotexture 25 cases,and solid-cystic mixed echogenicity 34 cases respectively.There were 36 cases testicular epidermoid cysts,which were all focal lesions including onion ring sign type 10 cases,peripheral(egg shell)calcification type 2 cases,solid-like echogenicity type 1 case,and heterogeneous echotexture type 23 case.23 cases yolk sac tumors included 8 cases diffused lesions which had 7 cases of slightly inhomogeneous echogenicity and one case of heterogeneous echotexture with no blood flow intratumor,and 15 cases focal lesions with 10 cases of homogeneous echogenicity and 5 cases of solid-cystic mixed echogenicity.There had unilateral diffused lymphoma 10 cases,bilateral multiple focal nodular type 3 cases,unilateral solitary focal lesion 6 cases,and unilateral multiple focal nodular type 3 cases.In this study,there had 21 cases of embryonal carcinoma,of which had 6 diffused cases with one solid type and five solid-cystic echotexture type,and 15 focal cases with 7 solid type and 5 solid-cystic mixed echogenicity.Three cases of focal embryonal carcinoma had 2 nodular respectively.5 cases of mixed germ cell tumor belonged to diffused lesions with 3 cases solid echogenicity type and 2 cases solid-cystic mixed echogenicity.There had 11 cases focal mixed germ cell tumor with 5 cases solid echogenicity type and 6 cases solid-cystic mixed echogenicity type.All 12 cases of Leydig cell tumor were focal lesions with 7 cases homogeneous echogenicity,4 cases inhomogeneous echotexture,and one case bilateral lesion.Leukemic infiltration to the testis had 6 cases,of which were 5 cases with diffused lesions and one case with focal lesion respectively.3 cases of Sertoli cell tumor were all focal lesion with 2 cases of homogeneous echotexture and one solid-cystic heterogeneous echogenicity.The two cases of metastases to the testis were all focal solid hypoechoic mass that primary tumors were prostate cancer and malignant melanoma respectively.One case of choriocarcinoma showed a diffused mass with nonspecific sonographic appearance.One case of adrenal rest revealed bilateral solid heterogeneous echotexture on sonogram and diffused enlargement of bilateral adrenal gland with an adenoma of the right adrenal gland on CT appearances.The statistics figure one to nine of the patients' age profile showed the patients' age distribution characteristic of seminoma,teratoma,epidermoid cyst,yolk sac tumor,lymphoma,embryonal carcinoma,mixed germ cell tumor,Leydig cell tumor,and leukemic infiltration to the testis respectively.The peak prevalence of seminomas occurred in the 31-40-year-old age group(41.8%,41/98).The main prevalence of teratomas happened in the 0-5-year-old age group(54.1%,40/74).The peak prevalence of epidermoid cysts occurred in the 11-20-year-old age group(52.8%,19/36).The marked peak prevalence of yolk sac tumors occurred in the 7-24-month-old age group(91.3%,21/23).The peak prevalence of lymphomas occurred in the more than 60-year-old age group(59.1%,13/22).The peak prevalence of embryonal carcinomas occurred in the 21-30-year-old age group(76.2%,16/21).The peak prevalence of mixed germ cell tumors occurred in the 21-40-year-old age group(62.5%,10/16).The peak prevalence of Leydig cell tumors occurred in the 31-50-year-old age group(66.7%,8/12).The peak prevalence of leukemia infiltration to testis occurred in the 6-10-year-old age group(66.7%,4/6).The statistics table one showed that the age of patients with yolk sac tumor,leukaemia testis infiltration and teratoma was low,especially the mean age of yolk sac tumors was 1.4-year-old,and the mean age of lymphomas was 58.6 year-old which was higher than any other testicular tumors.The mean ages of embryonal carcinomas and mixed germ cell tumors were 40.7-and 36.7-year-old respectively without statistically difference between them.By chi square test(x2= 63.854,P<0.001),the proportion of tumor manifesting a diffused lesion,leukemia infiltration to the testis,seminoma,and lymphoma was higher than that of other testicular tumors,which was statistically significant in statistics table 2.As shown in statistics table 3,in all kinds of testicular tumors included in the statistics,the mean maximum diameter of seminoma was the largest,5.67 cm,and the average maximum diameter of Leydig cell tumor was the smallest,1.77 cm.The mean maximum diameters of embryonal carcinoma and mixed germ cell tumor were 4.15 cm and 4.79 cm respectively and there was no statistical difference between them.In statistics table 4,by the comparison of chi square test(x2=105.027,P<0.001),the proportions of cystic changes of teratoma,embryonal carcinoma were higher than other testicular tumors.The proportion of cystic changes of mixed germ cell tumor was higher than seminoma,epidermoid cyst,and lymphoma,which had statistics significance,compared with other testicular tumors of no statistics significance.By the comparison of chi square test(x2=34.562,P<0.001)in statistics table 6,the incidence of seminoma with microlithiasis was higher than that of teratoma and epidermoid cyst,although there were difference with other types of testicular tumors,but the comparison by the Scheffe test for the multiple comparison between groups had not found statistically significant.By the comparison of chi square test(x2=40.079,P<0.001)in the statistics table 7,the incidence of metastatic rate of embryonal carcinoma was higher than other types of testicular tumors,the incidence of metastatic rate of mixed germ cell tumor was higher also,but without statistical significance.By the analysis of one-way ANOVA(F=0.677,P=0.668)in statistics table 8,there had blood flow in all testicular tumor,which had no statistics significance between groups and cannot effectively distinguish between various types of testicular tumor by PSV value.There had no blood flow signal in all testicular epidermoid cysts.The statistics table 9 showed that the maximum value of RI in all testicular tumors was 0.61,which belonged to low resistive pattern of blood flow,by the analysis of one-way ANOVA(F=1.289.P=0.273),which had no difference between groups and could not effectively distinguish and identify various types of testicular tumors by RI values.By the comparison of chi square test(x2=28.197,P<0.001)in the statistics table 10,the proportion of cryptorchidism patients with seminoma was higher than that of teratoma and testicular epidermoid cyst,and no statistical difference with other types of testicular tumors.By the comparison of chi square test(x2=139.682,P<0.001)in the statistics table 11,the positive proportion of serum AFP level of yolk sac tumors was the highest,next was mixed germ cell tumor and embryonal carcinoma,which were significantly higher than other types of testicular tumors.By the comparison of chi square test(x2=61.116,P<0.001)in the statistics table 12,the positive proportions of serum ?-HCG level of mixed germ cell tumor and embryonal carcinoma were higher than that of other types of testicular tumors.Conclusion High frequency ultrasonography can clearly show that the testicular tumor involving range of the affected testis(focal or diffused),number,size,echotexture(homogeneous or inhomogeneous),echogenicity characteristics(cystic changes and calcification),information of blood flow,involved condition of the tunica albuginea and epididymis,conditions of concurrent microlithiasis.Combining with the patients' age,the medical history of cryptorchidism,the condition of metastasis,the level of serum AFP and ?-HCG,we could distinguish the different types of testicular tumors.High frequency ultrasonography played an important role in the diagnosis and differential diagnosis of various types of testicular tumors.