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Original Report |
1
Department of Radiology, University of Chicago Hospitals, 5841 S. Maryland
Ave., Chicago, IL 60637.
2
Present address: Department of Radiology, Northwestern University Medical
School, 676 N. St. Clair St., Ste. 800, Chicago, IL 60611.
Received August 20, 2001;
accepted after revision October 11, 2001.
Address correspondence to D. D. Casalino.
Abstract
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CONCLUSION. In the absence of relevant clinical findings or an abnormal signal on color-flow or power Doppler sonography, a striated pattern of a testicle appears to have no clinical importance. It is presumed to represent fibrosis, and the patient most likely can be followed up clinically and sonographically rather than having to undergo surgical exploration.
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We describe five consecutive patients in whom a unilateral diffuse striated pattern of the testicle was identified and reevaluated using sonography.
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All five patients for whom we had data were imaged with a high-resolution (linear 9-5-MHz transducer) scanner (Elegra; Siemens, Issaquah, WA. Using the scanner's testes program, gray-scale, color-flow Doppler, and power Doppler imaging were performed in all these patients. The Doppler imaging was optimized for low-flow sensitivity using a gate of 2, filter at the low setting, and velocity scale ranging from 0-10 cm per sec. Gain settings were adjusted to just below background noise levels. Experienced sonographers and a sonologist scanned all the patients. Two experienced staff radiologists reviewed all images for comparison of the baseline and follow-up examinations. An abnormal testis was judged as smaller, larger, or the same size as the contralateral normal-appearing testis on the basis of obvious differences in size seen on gray-scale sonograms and at physical examinations performed by the radiologist. Color-flow Doppler sonograms were evaluated for the presence or absence of flow as well as for an increase in number and concentration of detectable vessels within the striated testis. The determination of vascularity was based on comparison with the normal-appearing contralateral testis.
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In comparing the baseline and follow-up sonographic examinations, we observed no significant differences. At the time of the follow-up examinations, three of the patients (patients 2, 4, and 5) were asymptomatic. Patient 1 reported occasional scrotal discomfort. Patient 3 reported persistent scrotal tenderness. None of the patients had a palpable testicular abnormality at the physical examination performed at the time of the follow-up sonographic studies.
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These striations have the same anatomic disposition as the interlobular septa, which extend from the mediastinum testis and are a component of the interstitium. Vessels and lymphatics run along these septa. In surgical pathology, processes known to cause interstitial infiltration include primary testicular neoplasm, particularly seminoma; leukemia; lymphoma; and orchitis. The striated pattern of the testicle on sonography has been described as a pattern associated with fibrosis in a case report [1] and with five cases of infiltrative non-Hodgkin's lymphoma [2, 3]. In these few patients, surgical exploration was performed. More recently, the striated pattern, also referred to as septal accentuation, has been described as a temporary finding in patients with acute orchitis and an occasionally persistent finding after clinical resolution of orchitis [4].
A differential diagnosis for a straited pattern of a testis should include neoplasm, orchitis, and fibrosis. Sonographic features—such as a focal mass, testicular size, Doppler findings, and chronicity—of an abnormality, as well as clinical features—such as the patient's age, history of malignancy, palpable testicular mass, and lymphadenopathy—can narrow this differential.
It is unlikely that the striated appearance of the testis was the result of a primary testicular tumor in any of our patients. In most testicular neoplasms, a focal mass or masses will be revealed on sonography. In a series of 29 testicular neoplasms, a focal mass or masses was seen in 21 cases [5]. In this same series, a diffuse texture change was the only sonographic abnormality in a case of infiltrative seminoma and in a case of infiltrative leukemia. Both cases resulted in testicular enlargement, a feature not found in any of our patients. Diffuse neoplastic involvement of a testicle usually results in an abnormal finding at clinical examination.
It is unlikely that the striated appearance was the result of leukemic involvement of the testis in any of our patients. Leukemic involvement of the testis is most often seen in childhood. In a case report of a patient with acute lymphoblastic leukemia, disease recurrence resulted in enlargement of the testis with two focal hypoechoic lesions, the larger measuring 2.5 cm [6]. In a series of three patients with testicular acute lymphocytic leukemia, all involved testes were enlarged and painless with either a diffuse or focal hypoechoic mass replacing most of normal testicular tissue [7].
It is also unlikely that the striated appearance was the result of lymphoma or metastatic involvement of the testis in any of our patients. In the five cases of infiltrative testicular non-Hodgkin's lymphoma that resulted in a striated pattern seen on sonography of the involved testes, the involved testes were substantially enlarged [2, 3]. In a series of six patients with testicular lymphoma and two patients with testicular leukemia, all involved testes were enlarged and painless [8]. In this same series, increased color-flow Doppler signal was seen in all areas of leukemic or lymphomatous involvement.
Orchitis can result in a striated pattern [4]. Acute orchitis, however, is usually associated with pain, epididymal enlargement, scrotal wall thickening, and testicular hypervascularity on color-flow Doppler imaging [4, 9]. Testicular hypervascularity was not found in any of our patients.
The sonographic and clinical findings and the stability of these findings over an approximately 1 year suggest that the unilateral striated pattern of the testicle is probably the result of a benign process—probably fibrosis—in our five patients. Fibrosis generally manifests as seminiferous tubule sclerosis and interstitial fibrosis that may be the result of acquired gonadotropin deficiency, karyotypic abnormalities, remote orchitis, torsion, cryptorchidism, radiation, aging, trauma, or idiopathic process. Three of our five patients had clinical histories that provided potential etiologies for fibrosis. Orchitis may have been associated with the reported ipsilateral epididymitis in patient 3 and may have resulted in testicular fibrosis. The ipsilateral inguinal hernia repair may have resulted in testicular ischemia and fibrosis in patient 4. Given the fact that there was no evidence of a diffuse testicular abnormality on a preoperative sonogram, the partial orchiectomy was almost certainly the etiology of fibrosis in patient 5.
Various patterns of fibrosis have been described, including the striated pattern, diffuse heterogeneity (not otherwise specified), focal hypoechoic masses, and focal hyperechoic masses, either unilateral or bilateral [1, 4, 10, 11]. Most testes with fibrosis are either small or of normal size, a pattern seen in all our patients. One case report has been published that describes a patient with an enlarged firm fibrotic testis that had been treated with chemotherapy and radiation therapy for leukemic involvement [12]. On sonography, this testis was diffusely heterogeneous with hypoechoic regions. The use of color-flow Doppler imaging was not described in this case report.
The small number of patients, lack of definitive histopathologic correlation, and relatively short follow-up period limit our study. It is uncertain whether a 1-year period of stability is sufficient to exclude an indolent inflammatory or infectious process or a slowly growing neoplasm. The unilateral nature of the striated pattern argues against the appearance of such a pattern being a normal finding.
In conclusion, we believe that in the absence of relevant clinical findings or abnormal findings on color-flow Doppler sonography, a striated pattern of a testicle is of no clinical importance and that patients with sonograms showing this pattern can probably be followed up clinically and sonographically rather than having to undergo surgical exploration.
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