Diagnostic Imaging Pathways - Scrotal Mass
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Population Covered By The Guidance
This pathway provides guidance on the imaging of adult male patients with a scrotal mass.
Date reviewed: January 2012
Date of next review: 2017/2018
Published: August 2012
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1 |  |
Testicular Cyst
Image 1 (Ultrasound): Left testicular cyst with no discernable wall or flow. |
| 2 |  |
Testicular Tumour
Image 2 (Ultrasound): Solid and cystic lesion with thick walls and marked vascularity in some areas. The appearances are consistent with a tumour. |
| 3a |  |
Testicular Tumour
Image 3a: Orchidectomy specimen showing complete replacement of the normal testicular parenchyma with the classical "cut-potato" appearance of a seminoma. The tunica albuginea is intact. |
| 3b |  |
Image 3b (H&E, x2.5): Histological section of a seminoma showing groups of malignant cells with large nuclei and prominent nucleoli. There are also intervening fibrous bands with an infiltrate of lymphocytes and plasma cells. |
| 4a |  |
Testicular Tumour
Image 4a (H&E, x2.5): Orchidectomy specimen showing a teratoma with areas of cyst formation and haemorrhage. |
| 4b |  |
Image 4b (H&E, x2.5): Histological section of a teratoma (non-seminomatous germ cell tumour) showing hyaline cartilage and islands of columnar epithelium. |
| 5 |  |
Scrotal Abscess
Image 5 (Ultrasound): A central mass lesion is located superficially and in the midline towards the inferior pole of the scrotum. It has a low echogenic rim but contains echogenic material with no discernable flow within the lesion. There is inflammation of the surrounding tissues. |
Teaching Points
Teaching Points
- Ultrasound can be used to differentiate between intra and extra testicular masses. It is also useful in differentiating solid from cystic masses
- A painless testicular mass on ultrasound requires further investigation, as a malignancy is highly likely
- Initial staging modalities include a CT of the abdomen and plain chest radiographs
ct
Computed Tomography (CT)
- Abdominal CT is the imaging modality of choice for staging of patients with testicular cancer 6
- Allows assessment of the retroperitoneum for the presence of metastatic disease 6
- Accuracy ranges between 73-97% with false-negative rates of 23-44% 7,8,9
- Chest CT is indicated when 6,8,10,11
- Abdominal CT is positive
- Tumour markers are persistently elevated
- Chest radiography findings are suspicious of pulmonary metastases
- Limitations - inability to detect metastatic disease in normal sized lymph nodes, and difficult interpretation in young men with paucity of retroperitoneal fat 6
us
Ultrasound
- Indications 1
- To confirm a clinical diagnosis of tumour and to assess contralateral testis
- To assess clinically solid scrotal masses
- To assess an impalpable testis within a hydrocoele
- To confirm a borderline clinical diagnosis of varicocoele in appropriate patients
- Used to differentiate between intra- and extra-testicular masses and can differentiate fluid filled lesions (eg hydrocoele, spermatocoele, haematocoele etc.) from solid intra-testicular tumours when clinical evaluation is in doubt 2
- 98% sensitivity and specificity for diagnosis of intra-scrotal neoplasia 3
- Limitations - hypervascularity of large tumours can be difficult to distinguish from that of inflammatory lesions 4,5
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Adeyoju AB, Collins GN, Pollard AJ, et al. A prospective evaluation of scrotal ultrasonography in clinical practice. BJU Int. 2000;86:87-8. (Level II evidence). View the reference
- Lau MWM, Taylor PM, Payne SR. The indications for scrotal ultrasound. Br J Radiol. 1999;72:833-7. (Level III evidence)
- Guthrie JA, Fowler RC. Ultrasound diagnosis of testicular tumours presenting as epididymal disease. Clin Radiol. 1992;46:397-400. (Level II evidence). View the reference
- Horstman WG, Melson GL, Middleton WD, et al. Testicular tumours: findings with colour Doppler US. Radiology. 1992;185(3):733-7. (Level IV evidence)
- Mazzu D, Jeffery Jr RB, Ralls PW. Lymphoma and leukemia involving the testicles: findings on gray-scale and colour Doppler sonography. AJR Am J Roentgenol. 1994;164:645-7. (Level IV evidence)
- Gatti JM, Stephenson RA. Staging of testis cancer: combining serum markers, histologic parameters, and radiographic imaging. Urol Clin North Am. 1998;25(3):397-403. (Review article)
- Richie JP, Garnick MB, Finberg H. Computerised tomography: how accurate for abdominal staging of testis tumours? J Urol. 1982;127:715-7. (Level II/III evidence)
- Moul JW. Proper staging techniques in testicular cancer. Tech Urol. 1995;1:126-32. (Review article)
- Samuelson L, Frostberg L, Olson A. Accuracy of radiological staging procedures in nonseminomatous testis cancer compared with findings from surgical exploration and histopathological studies of extirpated tissue. Br J Radiol. 1986;59:131-4. (Level III evidence)
- See WA, Hoxie L. Chest staging in testis cancer patients: imaging modality selection based upon risk assessment as determined by abdominal CT scan results. J Urol. 1993;150:874-8. (Level III evidence)
- Fernandez EB, Colon E, McLeod DG, et al. Efficacy of radiographic chest imaging in patients with testicular cancer. Urology. 1994;44:243-9. (Level III evidence)
Information for Consumers
Information for Consumers
Information from this website |
Information from the Royal Australian and New Zealand College of Radiologists’ website |
|
Consent to Procedure or Treatment Radiation Risks of X-rays and Scans |
Iodine-Containing Contrast Medium Radiation Risk of Medical Imaging for Adults and Children |
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