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  • Review Article
  • Published:

Contemporary diagnostic work-up of testicular germ cell tumours

Nature Reviews Urology volume 10, pages 703–712 (2013)Cite this article

Subjects

Key Points

  • Clinical assessment of testicular masses must involve evaluation of the risk factors for testicular cancer, namely undescended testes, familial testis cancer, and previous contralateral tumour

  • Grey-scale ultrasonography with high frequency probes (≥10 MHz or more) is the recommended first-line imaging modality for exploration of the scrotum

  • Colour Doppler ultrasonography is a valuable adjunct to grey-scale ultrasonography for the evaluation of testicular mass vascularization

  • Contrast-enhanced ultrasonography and real-time elastography are emerging techniques that can be used to characterize small intratesticular tumours <1 cm in diameter

  • Scrotal MRI is a powerful second-line imaging modality

  • Frozen section examination can be used during testicular surgery to identify suitable candidates for testis-sparing procedures

Abstract

Diagnostic work-up of testicular masses should begin with a complete patient history and palpation of the testes with both hands. First-line imaging of the scrotum should be performed using multiparametric ultrasonography, that is the sequential use of grey-scale ultrasonography, colour Doppler ultrasonography (CDUS), and, if available, contrast-enhanced ultrasonography (CEUS) and real-time elastography (RTE). Increased vascularization—a characteristic of malignancy and inflammation—is visualized on CDUS and CEUS. RTE provides additional information for distinguishing between benign and malignant tissue by measuring tissue elasticity of lesions. MRI is another powerful modality, typically used for second-line imaging of intrascrotal disorders. MRI can provide images with a broad field of view of the scrotal contents. Cancerous lesions are identified on MRI by their signal enhancement after injection of contrast agent. Testicular germ cell tumours require treatment by inguinal orchiectomy. Testis-sparing surgery is advocated for benign tumours and in solitary testicles provided the tumour is <3 cm and the preoperative serum testosterone level is normal. For intraoperative decision-making with regard to testis-sparing surgery, frozen section histological examination can be used, which has a false-negative rate of <10%.

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Figure 1: Features of a typical testicular seminoma.
Figure 2: Features of a typical nonseminomatous testicular tumour.
Figure 3: Contrast-enhanced ultrasonography of a small testicular seminoma.
Figure 4: Real-time elastography of a testicular nonseminoma.
Figure 5: Scrotal MRI of a small intratesticular tumour (1.5 T, surface coil).
Figure 6: Scrotal MRI of a typical testicular seminoma (1.5 T, surface coil).
Figure 7: Scrotal MRI of mixed nonseminomatous tumour (1.5 T, surface coil).
Figure 8: Testis-sparing surgery.

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Acknowledgements

The authors are grateful to Dr Evelyn Stolle, Dr Claudia Schröder and Dr Christa Schmidt for fruitful discussions and valuable advice during preparation of the manuscript.

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Authors and Affiliations

  1. Department of Urology, Albertinen-Krankenhaus, Suentelstrasse 11a, Hamburg, D-22457, Germany

    Klaus-Peter Dieckmann

  2. Department of Diagnostic Radiology, Albertinen-Krankenhaus, Suentelstrasse 11a, Hamburg, D-22457, Germany

    Ulrich Frey

  3. Department of Internal Medicine, Albertinen-Krankenhaus, Suentelstrasse 11a, Hamburg, D-22457, Germany

    Guntram Lock

Authors
  1. Klaus-Peter Dieckmann
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  2. Ulrich Frey
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  3. Guntram Lock
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Contributions

K.-P. Dieckmann and G. Lock researched data and wrote the article. All authors contributed to the discussion of content and reviewed the manuscript before submission.

Corresponding author

Correspondence to Klaus-Peter Dieckmann.

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The authors declare no competing financial interests.

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Dieckmann, KP., Frey, U. & Lock, G. Contemporary diagnostic work-up of testicular germ cell tumours. Nat Rev Urol 10, 703–712 (2013). https://doi.org/10.1038/nrurol.2013.254

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