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Correlation of Radionucide Imaging and Diagnostic Ultrasound in Scrotal Diseases

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Correlation of Radionucide Imaging and Diagnostic Ultrasound in Scrotal Diseases Correlation of Radionucide Imaging and Diagnostic Ultrasound in Scrotal Diseases David C.P. Chen, Lawrence E. Holder, and Gerson N. Kaplan Department ofRadiology, Division ofNuclear Medicine, The Union Memorial Hospital; and the Johns Hopkins Medical Institutions; Baltimore, Maryland A retrospective study was performed to evaluate the comparative usefulness of scrotal ultrasound imaging (SU) and radionudide scrotal imaging (ASI) in 46 patients. The final diagnosis included four late phase and one early testicular torsion (TT), 11 acute epididymitis (AE), four subacute apididymitis (SE), six malignant tumors, ten hydroceles or other cystic lesions, and ten miscellaneous lesions. In patients with scrotal pain, 3/4 with late phase TI were correctly diagnosed by SU, whileone with early TI and 11/15 with AE or SE were not diagnosed. Allof them were correctly diagnosed with ASI except one with scrotal cyst. SU was able to separate cystic masses (n = 10) from solid masses (n = 9), but could not separate malignant from benign lesions. ASI had difficufty in separating cystic from solid lesions. We conduded that SU is useful in patients with scrotal mass to separate solid from cystic lesions. However, SU is unable to differentiate acute epididymitis from early testicular torsion. Therefore, in patients with acute scrotal pain, ASI should still be the first study performed. J Nuci Med 27:1774—1781,1986 ore than 10 years' experience with radionuclide MATERIALS AND METhODS scrotal imaging (RSI) has confirmed the value of this imaging modality in managing patients with acute scro Patient Population tal pain. Two recent reviews (1,2) summarize this ex From January, 1978, through May, 1983, 61 patients perience. With an understanding of the anatomic and had SU, 232 had RSI, with 52 having both SU and RSI. pathophysiologic bases ofthe RSI findings, earlytestic Final diagnoses were obtained surgically in 26 patients ular torsion and acute epididymitis can be accurately and by clinical followup ofat least 6 mo in 20 patients. differentiated (3—5). These 46 patients (5 1 studies) form the data base of this Advances in instrumentation have encouraged inves report. The remaining six patients did not return to the tigators to evaluate the use of ultrasound in the diag referring physician for follow-up and were excluded nosis of patients with scrotal masses (6—13),testicular from the study. The age range of the patients was 16 to torsion (13,14), diseases of the epididymis (10,11,13, 75 yr. Clinically these patients presented with: (a) acute 15), and testicular trauma (13,16,1 7). The correlation scrotal pain (n = 17), which was ofrapid onset, usually of these two modalities is the subject of this communi occurring within the previous 24 hr, but occasionally cation. Both scrotal ultrasonography (SU) and radio up to 5 days before presentation, (b) subacute scrotal nuclide scrotal imaging (RSI) were performed in four pain (n = 6), which lasted in excess of 5 days, and may groups of patients with relatively distinct clinical pre have been intermittent or chronic (over a month), (c) sentations: (a) acute scrotal pain, (b) subacute scrotal scrotal mass (n = 19) as the primary complaint, and (d) pain, (c) scrotal mass, and (d) scrotal trauma. Clinical scrotal trauma (n = 4) which included patients with protocols for the use of these modalities in different direct trauma. clinical situations are then suggested and their rationale discussed. Scrotal Ultrasonography Three different instruments were used during the study period. In the early years (1978—1981), a static B ReceivedJuly 29, 1985;revisionaccepted Aug. 1, 1986. For reprints contact: David C.P. Chen, MD, Div. of Nuclear scan gray-scale instrument utilizing a five MHz trans Medicine, University of Southern California, 1200 North State ducer with a 7-mm-diameter crystal and a short internal St., Los Angeles,CA 90033. focus was used (32 patients). Subsequently, real time 1774 Chen,Holder,andKaplan The Journal of Nuclear Medicine ultrasonic scanning was done (14 patients). In three The RSI studies were reviewed by an experienced patients, a scanner with a 3.5 MHz transducer was nuclear medicine physician (L.E.H.). The interpretation used,t and in 11 patients, a scanner with a 7.5 MHz of the scrotal RNA and scan followed a systematic small parts transducer* was used. Five patients were approach, which was recently reported (1,4). The inter examined with both static B scan and real time scanning val between the SU and RSI was <24 hr in each case. instruments. All studies were performed with the direct Normal Study contact method. No Doppler was used. A normal SU examination was well described (14). The ultrasonograms were reviewed by an experienced The normal testes are ovoid and contain homogeneous sonologist (G.N.K.) without knowledge of the clinical fine echogenicity of medium strength. The epididymis history. The size and echogenicity of the testes and can frequently be seen as a dense echogenic band at the epididymis and the presence and characteristics of an periphery of the testis. intratesticular or extratesticular mass, hydrocele, he The normal RSI has been well described (1,3). matocele, or spermatocele were recorded in each study. Briefly, in the RNA there is no definition of testicular Skin thickness was also evaluated. or deferential vessels, which pass through the spermatic Radionuclide Scrotal Imaging cord, or pudendal vessels which lie outside the cord. RSI was performed as previously described (3,4). In No significant activity is seen in the scrotal region. In adults, 15—20mCi technetium-99m pertechnetate is the scrotal scan, testicular activity is symmetrical and injected as an i.v. bolus. Six or eight sequential 5-sec slightly more intense than thigh activity. frames are acquired with a gamma camera beginning with the first appearance of tracer on the persistence oscilloscope, or after a 10-sec delay following injection, RESULTS whichever comes first. This is called the radionuclide angiogram (RNA) or flow phase. The scrotal scan or AcuteScrotalPain(n= 17) tissue phase image is obtained for 700k counts imme The final diagnoses are shown in Table 1. All five diately after the RNA images are completed. A con patients with torsion were operated. In four patients verging collimator is used for both phases. with late phase torsion (1 day after scrotal pain), SU TABLE 1 FinalDiagnosis andDiagnostic Sensitivityof SU and ASI in Patients with Scrotal Diseases detectedFinal Sensitivity@ NumberofLesions Diagnosis patientsSU RSI SU RSI Acute scrotal pain 47% 94% Earlytorsion I 0 1 Late phase torsion 4 4 4 Acute epididymitis 11 3 11 Cyst 1 0 Subacutescrotalpain 50% 100% Subacuteepididymitis 414I11111 Atrophywith hydrocele Normal Scrotalmasst 100% 84% Solidmass Malignanttumor 6 6 6* Gumma 1 1 1 lntratesticularhematoma 2 2 1@ Cystic lesion Hydroceleor other cystic lesions 887'22222111II0 Atrophywith hydrocele Scrotal trauma 100% 75% Hematocele/hydrocele Traumaticepididymitiswith hydrocele Intratesticularabscess - Sensitivity of mOdality is expressed as lesion detected/total lesions present. t Su can separate cystic from solid masses, but cannot differentiate among various types of cystic lesions or solid masses. ASI cannot alwaysdifferentiatecysticfromsolidmasses. However,certain malignanttumors, such as seminomas, often had a charactenstic RSIpattern. * ASI had typical pattern in 3/4 seminomas. I Three lesions were 1 cm in size and were not detected by RSl. Volume27 •Number 11 •November1986 1775 @ .@ @, . demonstrated increased testicular size with generally of activity extending medially from the iliac artery. It decreased inhomogeneous echogenicity (Fig. lB). In may be due to reactive, increased blood flow in sper one of these patients, an earlier SU study performed 22 matic cord vessels, terminating abruptly at the site of hr after the onset of scrotal pain, demonstrated only the twist. slight enlargement of the testis, with subtle coarsening Only one patient presented with early testicular tor of the echo pattern (Fig 1A). RSI, in all four patients sion. SU was performed 5 hr after onset of pain and (five studies), had the typical “halo-like―appearance of demonstrated a normal testicle with inhomogeneous late phase torsion, with moderate decreased activity in echogenicity in the epididymis. In contrast, the RSI the testis and markedly increased activity in the dartos demonstrated an avascular testicle with no increased on delayed images (Fig. lC). The RNA perfusion pat activity in the dartos, which is the typical pattern for tern demonstrated no increased perfusion through the early torsion (1,5) (Fig. 2). Immediate surgery was spermatic cord vessels. Occasionally, in some patients, performed. The testicle was purplish blue, but there was there may be increased perfusion through the extra no hemorrhage or necrosis. The spermatic cord had cord vessels to the scrotum in late phase torsion. Often, twisted only 180°.Bilateral orchiopexy was done. there is a “nubbinsign,―which is visualized as a bump Eleven patients had acute inflammation that re sponded to antibiotic treatment. Pathologic results in five operated patients confirmed acute epididymitis without any evidence of testicular torsion. SU was abnormal in only three of eight patients with acute epididymitis, demonstrating an enlarged epididymis with relative coarse and decreased echogenicity (Fig. 3A). Three incidental hydroceles were seen. RSI dem onstrated acute epididymitis in all eight patients utiliz ing previously defined criteria (1,3). Briefly, increased perfusion through the vessels ofthe spermatic cord and to the lateral aspect of the hemiscrotum is noted in the RNA. Linear or curvilinear increased activity to the head, body, and tail of the epididymis is seen in the scrotal scan (Fig. 3B). SU was also normal, while RSI ,. FIGURE I Late phase torsion. A:Scrotal ultrasound 22 hr post onset of pain. Transverse scan. Normal right testicle contrasts to slightlyenlarged left testis with coarse echoes. Aight (A); Left (L). B: 3 days post onset of pain. Transverse scan. Aight testicle remains normal.
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