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Original Report |
1
Department of Radiology, Assaf Harofeh Medical Center, Zerifin 70300,
Israel.
2
Department of Radiology, Rabin Medical Center, Beilinson Campus, Petach Tikva
49100, Israel.
3
IVF and Infertility Unit, Rabin Medical Center, Beilinson Campus, Petach Tikva
49100, Israel.
4
IVF and Infertility Unit, Assaf Harofeh Medical Center, Zerifin 70300,
Israel.
Received April 25, 2000;
accepted after revision June 20, 2000.
Address correspondence to S. Strauss.
Abstract
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CONCLUSION. Although many urologists believe that solid intratesticular masses are malignant until proven otherwise, a growing number of benign focal testicular lesions have been described. Awareness of the cause and sonographic appearance of focal abnormalities in men who have undergone testicular aspiration or extraction should help radiologists suggest the correct diagnosis and advise a conservative approach on the basis of close surveillance by serial physical, laboratory, and imaging studies.
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In recent years, an increasing number of azoospermic men are undergoing retrieval of spermatozoa from the testis for intracytoplasmic sperm injection. Testicular sperm retrieval may be achieved by extraction at open biopsy or by percutaneous aspiration. Recent reports have appeared in the nonradiology literature describing the consequences on the testis of sperm extraction and aspiration [4,5,6]. The purpose of this study is to describe the sonographic features of focal intratesticular lesions seen more than 6 months after sperm retrieval procedures.
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Sonograms were obtained using either an HDI 3000 (Advanced Technology Laboratories, Bothell, WA) or a 128 (Acuson, Mountain View, CA) scanner using a 7- to 10-MHz linear transducer. Sonography was reviewed for echogenicity and location of the lesion, the size of the mass, and the presence of detectable blood flow on color or power Doppler sonography.
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The hypoechoic lesions were all round or elliptic. All eight hyperechoic lesions were subcapsular in location in the anterior region of the testis, most appearing as a small linear echogenic focus with posterior acoustic shadowing (Fig. 3). In three testes, the lesion had a mixed pattern, with both hypo- and hyperechoic areas (Fig. 4); these lesions were situated in the anterior zone of the testis. A predominantly cystic-appearing mass was found in one testis (Fig. 5). Lesions measured between 3 and 12 mm (mean, 6 mm) in maximum diameter. Color and power Doppler sonography of the masses did not show flow in any patient. Repeated sonography in five patients at monthly intervals, performed up to 13 months after the procedure, showed no change in the size or echogenicity pattern of the focal abnormality.
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With the increasing use of testicular biopsy to retrieve spermatozoa in subfertile men, several reports have described the consequences on the testis of the procedure. Harrington et al. [4] compared percutaneous with open biopsy of the testis and found that 10 (29%) of 34 open biopsies showed intratesticular bleeding or a new area of increased echogenicity 1 month after the procedure. These areas of increased echogenicity were interpreted as parenchymatous scars and were present 6 months after the procedure. Of 58 percutaneous biopsies, they found evidence of intratesticular bleeding characterized by a hypoechoic mass in four (7%). In all four patients, the hematoma resolved in 3-6 months after the procedure. Schlegel and Su [5] found sonographic evidence of hematoma or resolving inflammation in 82% of patients 3 months after testicular sperm extraction was performed, despite an outwardly normal scrotal examination. At 6 or more months, nine (65%) of 14 patients had changes consistent with parenchymal calcifications or linear scars, and three (21%) had findings consistent with acute inflammation or hematoma. Ron-El et al. [6] found focal testicular lesions in 17 (65%) of 26 testes examined at 2 months and in 14 (54%) of 26 testes examined at 6 months.
Both percutaneous and open biopsies of the testis have the potential for inadvertent vascular injury to the testis. In a study of 64 patients who underwent sperm extraction for nonobstructive azoospermia, Schlegel and Su [5] found impaired testicular blood flow in two patients who developed testicular atrophy. Therefore, it is likely that the focal lesions of increased or decreased echogenicity seen after sperm retrieval procedures correspond to discrete areas of parenchymal hemorrhage or infarction. In all our patients, the focal masses appeared avascular on color and power Doppler sonography. However, the absence of blood flow on Doppler sonography cannot exclude the possibility of neoplasm because 86% of tumors smaller than 1.6 cm were found to be hypovascular in a study by Horstman et al. [11].
In our study, eight lesions were hyperechoic, and three contained both hypo- and hyperechoic regions. Most of these eleven lesions had foci of calcification. The differential diagnosis of echogenic intratesticular lesions with calcification includes benign conditions such as prior trauma, resolved inflammatory disease, and segmented infarction. However, these sonographic features may also be found in malignant tumors, including teratocarcinoma,metastaticcarcinoidtumor,seminoma,and embryonal cell carcinoma. Stromal neoplasms of the testis, such as Leydig's cell tumor and Sertoli's cell tumor, may also appear on sonography as focal areas of dense calcification [12]. Rarely, a calcific scar may represent a regressed or "burned-out" tumor, and the occult neoplasm is discovered only on evaluation for metastatic disease.
The single lesion in our series that was predominantly cystic could have also been mistaken for an embryonal cell tumor, although these cystic areas are usually found in larger, predominantly solid masses [8].
A limitation of our study is the lack of histologic proof. However, it
would be unreasonable to recommend surgery for patients with lesions that are
presumed to be benign. In this series, several factors supported our
consideration of conservative treatment, including a prior history of
testicular sperm extraction or aspiration (even if performed > 1 year
previously), the absence of a palpable testicular mass or signs of
extratesticular malignancy, and the location of the lesion subcapsularly or in
the anterior zone of the testis on sonography. Additionally, supportive
evidence of a benign cause was obtained by the unchanged appearance of lesions
in five patients who had follow-up sonography for several months. We recommend
that patients with an intratesticular lesion thought to be associated with
sperm retrieval procedures be closely monitored by serial physical and imaging
studies, as well as the measurement of serum tumor markers such as
ß-human chorionic gonadotropin and 
-fetoprotein.
A preprocedural scrotal sonogram is useful as baseline documentation of the testes and is also warranted because of the greater risk of testicular cancer in subfertile men [13].
In conclusion, focal intratesticular lesions may be incidentally found in men who have previously undergone sperm retrieval procedures. Awareness of this nonneoplastic entity is important to avoid misinterpretation of the lesion as a malignant tumor. A careful history is necessary to suggest the diagnosis. The patient may be reluctant to volunteer an infertility problem and may not be forthcoming with a history of sperm aspiration or extraction in the past. Additionally, biopsy of the testis, whether by percutaneous aspiration or open extraction, is unlikely to leave skin markings on the scrotum visible to the radiologist. In the correct clinical setting, sonographic findings may suggest that the mass is benign and that a conservative approach be advised. However, in some patients in whom the mass cannot be confidently characterized as benign (or the patient is not reliable enough to return for follow-up assessment), the surgeon may consider intraoperative frozen section biopsy and testicular preservation surgery if malignancy is not found.
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