Contrast-Enhanced Ultrasound and Real-Time Elastography for the Diagnosis of Benign Leydig Cell Tumors of the Testis – A Single Center Report on 13 Cases

Abstract

Purpose: To describe sonomorphological features in testicular Leydig cell tumors (LCTs) with a special focus on contrast-enhanced ultrasonography (CEUS) and real-time elastography (RTE).

Patients and Methods: In a series of 186 patients with testicular surgery for neoplastic disease, 13 benign LCTs (in 12 patients) were histopathologically diagnosed. Preoperatively, all patients had been examined with a standardized protocol (high-resolution grayscale and color-coded ultrasonography, CEUS). 5 patients underwent RTE. In CEUS, the filling time of the lesion was compared to that of 14 size-matched germ cell tumors (GCT).

Results: 10/13 LCTs had a size of < 10 mm, and a sharply demarcated hypoechoic appearance was typical (10/13). Color-coded ultrasonography detected signals in 8 lesions, while CEUS showed clear hypervascularization in all. LCTs had a significantly shorter filling time than GCTs (p < 0.0005), with 9/13 LCTs being completely filled within 4 s. In RTE, all 5 examined lesions were clearly “harder” than the surrounding testicular tissue.

Conclusion: Contrary to some earlier reports, we could demonstrate marked hypervascularization in LCTs. This feature clearly allows for the differentiation of a small LCT from focal scars. However, it may only be visible on CEUS. In CEUS, LCT is suggested by the findings of a short filling time or by a circumferential vessel with a rapid centripetal filling, combined with a “harder” appearance in RTE. These features along with the findings of a small and peripherally situated hypoechoic tumor would justify an operative strategy with frozen section examination and possibly organ sparing surgery instead of orchiectomy.

Zusammenfassung

Ziel: Die Beschreibung sonomorphologischer Charakteristika von Leydigzelltumoren (LZT) des Hodens, insbesondere der Kontrastmittel(KM)sonografie (CEUS) und der Elastografie (RTE).

Patienten und Methoden: Bei 186 wegen einer Neubildung des Hodens operierten Patienten fanden sich histopathologisch 13 benigne LZT (in 12 Patienten). Alle Patienten waren präoperativ nach einem standardisierten Protokoll untersucht worden (hochauflösende B-Bild und Farbdopplersonografie, CEUS), 5 Patienten zusätzlich mit RTE. Im CEUS Modus wurde die Zuflutzeit der LZT Läsionen mit der von 14 größenvergleichbaren Keimzelltumoren (GCT) verglichen.

Ergebnisse: 10/13 LZT wiesen eine Größe von < 10 mm auf. Im B-Bild fand sich typischerweise eine scharf abgrenzbare echoarme Läsion (10/13). Im Farbduplex zeigten sich Signale in 8 Läsionen, in der CEUS dagegen eine eindeutige Hypervaskularisation in allen Tumoren. Im Vergleich zu GCT war die Füllungszeit bei LZT signifikant kürzer (p < 0,0005); 9/13 LZTS waren innerhalb von 4 s komplett mit KM gefüllt. In der RTE waren alle 5 untersuchten Läsionen eindeutig “härter” als das umgebende Hodengewebe.

Schlussfolgerung: Entgegen früherer Berichte konnten wir bei LZTs eine klare Hypervaskularisation nachweisen. Dafür ist allerdings die CEUS erforderlich, die eine eindeutige Abgrenzung von kleinen LZTs gegen umschriebene Narben erlaubt. Hinweise für einen LZT sind eine kurze Anflutzeit des KM oder ein circumferentielles Gefäß mit einem schnellen centripetalen KM-Einstrom sowie eine größere „Härte“ in der RTE. Bei Vorliegen dieser Charakteristika in einem kleinen peripher gelegenen echoarmen Tumor erscheint eine operative Strategie mit Gefrierschnittuntersuchung und organsparendem Vorgehen anstelle einer Orchiektomie gerechtfertigt.

Key words

testes - contrast-enhanced ultrasound - elastography - Leydig cell tumor

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